For Neal Shah, the breaking level got here throughout his spouse’s most cancers remedy. He remembers being overwhelmed, surrounded by stacks of hospital payments, denial notices and insurance coverage statements. When he and his spouse tallied all the things — from month-to-month premiums and out-of-pocket prices to uncovered remedies — they realized the stunning fact that over time, they may have been higher off paying fully out of pocket than carrying medical health insurance in any respect. At first, Shah chalked all the payments and denials as much as dangerous luck. “Then, I went down a rabbit hole of research, of just trying to figure out what is going on with health insurance?” he instructed 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 grew to become the seed for CareYaya, a North Carolina-based firm Shah launched to attach faculty college students getting into the well being care area with households in want of reasonably priced caregiving. But at the same time as CareYaya grew, Shah saved encountering the all-too-familiar scenario of sufferers, caregivers and college students fully overwhelmed by medical health 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 12 months, Shah launched one other startup, Counterforce Health, which gives 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 device does the heavy lifting of translating dense well being care insurance policies and scientific 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 looking for assist. Counterforce is attempting 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 out to be 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 remedies their medical doctors suggest. The numbers inform their very own tragic story. According to information from KFF, 20% of all claims throughout Affordable Care Act market plans have been denied in 2023. ACA plans coated greater than 20 million Americans initially 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 current 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 12 months, a class-action lawsuit accused UnitedHealth of deploying its AI device, generally known as nH Predict, to chop off care prematurely for aged Medicare sufferers, no matter their medical doctors’ suggestions. That lawsuit was filed in 2023, a 12 months earlier than the killing of then-UnitedHealth CEO Brian Thompson, which intensified nationwide scrutiny of how insurance coverage giants use denials to regulate prices. Critics, like Shah, say these programs scale 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 huge medical health 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 scientific analysis and different appeals which have succeeded below related circumstances. The objective is to create tailor-made, evidence-driven appeals which are laborious for insurers to dismiss, whereas additionally saving sufferers and their households tons of of hours of analysis and drafting enchantment letters. Many sufferers merely haven’t got the time, power or assets to combat appeals. As Dr. David Casarett, a professor of drugs at Duke and part chief of palliative care at Duke Health, instructed CNET, some sufferers “step into the ring with boxing gloves on,” however many simply quit, go into debt or forgo remedy 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 needed remedy. Because she and her husband had superior scientific backgrounds, and a son with a medical diploma, they meticulously tracked appeals and sometimes gained. “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 remedies that might in any other case have been out of attain. Shah’s longer-term imaginative and prescient is for instruments like Counterforce to turn out to be 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 device, value was a giant 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 heart growing AI and tech to assist growing older and independence. Shah mentioned preserving this device 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 type 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 12 months by 2022. Adding a further $300 to $1,000 to rent assist to put in writing 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 info, you must all the time think about privateness. Counterforce Health collects private and health-related information — equivalent to your insurance coverage particulars, denial letters and medical background — to generate appeals. The firm states that it doesn’t promote this info, makes use of encryption and different safeguards to guard it, and solely shares information with trusted service suppliers or third events below confidentiality and authorized compliance necessities. To get began with Counterforce Health, you may go to the homepage, click on “Start Free Appeal” and you will be prompted to fill out a short questionnaire of knowledge, equivalent 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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