For Neal Shah, the breaking level got here throughout his spouse’s most cancers therapy. He remembers being overwhelmed, surrounded by stacks of hospital payments, denial notices and insurance coverage statements. When he and his spouse tallied every thing — from month-to-month premiums and out-of-pocket prices to uncovered therapies — they realized the surprising fact that through the years, they could have been higher off paying fully out of pocket than carrying medical insurance in any respect. At first, Shah chalked the entire payments and denials as much as unhealthy luck. “Then, I went down a rabbit hole of research, of just trying to figure out what is going on with health insurance?” he informed CNET. “Why are there so many denials of claims? How many people is it impacting? And then I just got obsessive about it.” Zooey Liao/CNETThat obsessiveness and frustration turned the seed for CareYaya, a North Carolina-based firm Shah launched to attach school college students coming into the well being care discipline with households in want of inexpensive caregiving. But whilst CareYaya grew, Shah saved encountering the all-too-familiar scenario of sufferers, caregivers and college students utterly overwhelmed by medical insurance declare denials. “I realized I’m not alone and the people using CareYaya are not alone,” Shah mentioned. “There are millions of Americans dealing with this problem. People are drowning in denial claims.” Last yr, Shah launched one other startup, Counterforce Health, which affords a free platform that generates personalized insurance coverage enchantment letters in minutes. Counterforce’s platform permits sufferers or clinics to add denial letters and related medical information. The system analyzes insurance coverage insurance policies, critiques medical literature and attracts from profitable appeals to supply a draft response. Users can edit the letter earlier than submitting it, however the AI software does the heavy lifting of translating dense well being care insurance policies and medical arguments and structuring an enchantment. As denials climb nationwide and debates about moral AI use ramp up, the corporate’s arrival comes at a pivotal second. Health insurers are more and more turning to AI to evaluate claims, which is leading to extra denials and frustration for sufferers in search of assist. Counterforce is making an attempt to flip the script, utilizing AI to not block protection however to assist sufferers win it again. Essentially, AI is preventing AI. Don’t miss any of our unbiased tech content material and lab-based critiques. Add CNET as a most popular Google supply on Chrome. Denials on the rise nationwide Health insurance coverage denials have turn into a defining characteristic of the American well being care system. Patients pay rising premiums, deductibles and copays, solely to seek out that insurers typically refuse to cowl the therapies their docs suggest. The numbers inform their very own tragic story. According to information from KFF, 20% of all claims throughout Affordable Care Act market plans had been denied in 2023. ACA plans coated greater than 20 million Americans in the beginning of 2025. Audits have discovered that insurers wrongly deny or delay hundreds of thousands of requests for care annually in Medicare Advantage, which covers greater than 30 million Americans. Yet appeals stay uncommon. Fewer than 1% of ACA plan denials are challenged. “Ninety-nine percent of patients or family caregivers do not appeal,” Shah mentioned. “Of the tiny fraction who do, 40% win. That tells you most people are intimidated, don’t know their rights or just assume a denial is final. And it also shows how frivolous so many of these denials are.” In latest years, AI has amplified this imbalance. Major insurers have turned to AI instruments that scan medical information, apply protection guidelines and generate denial letters in bulk. Investigations have discovered some algorithms making near-instantaneous denials, even when the treating supplier advisable the care. In 2022, a ProPublica investigation revealed that Cigna used an AI-driven algorithm to disclaim greater than 30,000 claims in simply two months, typically with out a human doctor ever reviewing the information. The following yr, a class-action lawsuit accused UnitedHealth of deploying its AI software, referred to as nH Predict, to chop off care prematurely for aged Medicare sufferers, no matter their docs’ suggestions. That lawsuit was filed in 2023, a yr earlier than the killing of then-UnitedHealth CEO Brian Thompson, which intensified nationwide scrutiny of how insurance coverage giants use denials to manage prices. Critics, like Shah, say these programs cut back sufferers to information factors, prioritizing prices over ethics. “Writing an appeal letter can take eight hours between digging through billing codes, medical journals and citations,” Shah mentioned. “For the average American, that’s like a full-time job on top of everything else they’re dealing with.” Patients are sometimes required to enter a nauseating loop when coping with the well being care system: claims are filed, claims are denied by machines, enchantment processes are buried and, finally, life-altering care is delayed or deserted altogether. Flipping the script Against this backdrop of rising denials and AI-automated gatekeeping, Counterforce Health is positioning itself as a counterpunch, going lick for lick with massive medical insurance corporations deploying AI to disclaim claims. Instead of sufferers drowning in paperwork or giving up, the Counterforce platform arms them with the instruments to push again rapidly and successfully. “Right now, insurers are using AI to deny claims in seconds, while patients and doctors spend hours fighting back,” Shah mentioned. “That’s not a fair fight. Our mission is to flip the script and make appeals as easy as one click.” When a denial letter is uploaded, Counterforce’s system does not simply produce boilerplate textual content; it analyzes the insurer’s rationale and attracts on medical analysis and different appeals which have succeeded underneath related circumstances. The purpose is to create tailor-made, evidence-driven appeals which might be onerous for insurers to dismiss, whereas additionally saving sufferers and their households lots of of hours of analysis and drafting enchantment letters. Many sufferers merely do not have the time, vitality or sources to combat appeals. As Dr. David Casarett, a professor of medication at Duke and part chief of palliative care at Duke Health, informed CNET, some sufferers “step into the ring with boxing gloves on,” however many simply surrender, go into debt or forgo therapy altogether. Casarett works with CareYaya as a accomplice doctor. Casarett’s mom battled a number of myeloma, a most cancers of the blood’s plasma cells, and confronted repeated insurance coverage denials for dear but crucial medicine. Because she and her husband had superior scientific backgrounds, and a son with a medical diploma, they meticulously tracked appeals and infrequently received. “Our appeals were successful,” he mentioned. “But what about everybody else? What prayer does a single mom with two jobs and a high school education have against a multibillion-dollar insurance industry?” The group has expanded past its pilot program at Wilmington Health’s rheumatology clinic in North Carolina to clinics and hospitals across the US, providing free entry to sufferers and caregivers. Shah mentioned 1000’s of sufferers have used Counterforce’s instruments to overturn denials for therapies that may in any other case have been out of attain. Shah’s longer-term imaginative and prescient is for instruments like Counterforce to turn into trusted, goal arbiters — the place sufferers and insurers acknowledge their appeals as legitimate, dependable and evidence-based. Lowering the associated fee barrier with AI When requested why particularly AI was chosen to be the go-to software, price was an enormous caveat. Counterforce is free to make use of due to funding from a number of grants and investments from enterprise companions, together with a $2.47 million grant from PennAITech, a University of Pennsylvania analysis middle growing AI and tech to assist ageing and independence. Shah mentioned preserving this software accessible was a precedence to permit extra individuals the chance to enchantment. While there are alternatives to rent affected person advocates to evaluate denials and kind appeals, they are often dear, starting from $80 to $150 per hour, relying on the advocate’s set charges. According to a 2025 report from KFF, the typical out-of-pocket spending for well being care providers had reached $1,425 per particular person per yr by 2022. Adding an extra $300 to $1,000 to rent assist to write down an enchantment is probably going not possible for a lot of low-income or middle-class Americans. “Right now, appealing is really for the rich, or I would even say the ultra-rich,” Shah mentioned. “To solve this problem, [we had] to figure out a way to do it for free or dirt cheap because people don’t have $300 to spend on a patient advocate when they can’t afford the medicine they critically need. We thought AI would be the perfect use case because the ongoing cost per user is literally pennies.” For now, Shah mentioned Counterforce intends to stay free for people. How to get began with Counterforce Health Before starting with any service that collects delicate well being data, it’s best to all the time contemplate privateness. Counterforce Health collects private and health-related information — corresponding to your insurance coverage particulars, denial letters and medical background — to generate appeals. The firm states that it doesn’t promote this data, makes use of encryption and different safeguards to guard it, and solely shares information with trusted service suppliers or third events underneath confidentiality and authorized compliance necessities. To get began with Counterforce Health, you possibly can go to the homepage, click on “Start Free Appeal” and you will be prompted to fill out a quick questionnaire of knowledge, corresponding to why you are visiting the web site and primary details about your insurance coverage denial. From there, you’ll present your denial letter and insurance coverage particulars, and the system’s AI generates a totally drafted, editable enchantment able to submit.
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