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 pieces — from month-to-month premiums and out-of-pocket prices to uncovered remedies — they realized the stunning fact that through the years, they could have been higher off paying solely out of pocket than carrying medical health insurance in any respect.
At first, Shah chalked the entire payments and denials as much as dangerous luck.
“Then, I went down a rabbit gap of analysis, of simply making an attempt to determine what’s going on with medical health insurance?” he advised CNET. “Why are there so many denials of claims? How many individuals is it impacting? After which I simply received obsessive about it.”
That obsessiveness and frustration turned the seed for CareYaya, a North Carolina-based firm Shah launched to attach school college students getting into the well being care discipline with households in want of inexpensive caregiving. However whilst CareYaya grew, Shah stored encountering the all-too-familiar state of affairs of sufferers, caregivers and college students fully overwhelmed by medical health insurance declare denials.
“I noticed I am not alone and the folks utilizing CareYaya aren’t alone,” Shah mentioned. “There are hundreds of thousands of Individuals coping with this drawback. Individuals are drowning in denial claims.”
Final 12 months, 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, evaluations medical literature and attracts from profitable appeals to provide a draft response. Customers 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 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. Well being insurers are more and more turning to AI to evaluation claims, which is leading to extra denials and frustration for sufferers looking for assist. Counterforce is making an attempt to flip the script, utilizing AI to not block protection however to assist sufferers win it again.
Basically, AI is preventing AI.
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Denials on the rise nationwide
Medical health insurance denials have change into a defining function of the American well being care system. Sufferers pay rising premiums, deductibles and copays, solely to seek out that insurers typically refuse to cowl the remedies their medical doctors advocate.
The numbers inform their very own tragic story.
In keeping with knowledge from KFF, 20% of all claims throughout Reasonably priced Care Act market plans have been denied in 2023. ACA plans lined 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 Benefit, which covers greater than 30 million Individuals.
But appeals stay uncommon. Fewer than 1% of ACA plan denials are challenged.
“Ninety-nine % of sufferers or household caregivers don’t enchantment,” Shah mentioned. “Of the tiny fraction who do, 40% win. That tells you most individuals are intimidated, do not know their rights or simply assume a denial is closing. And it additionally reveals how frivolous so many of those denials are.”
Lately, AI has amplified this imbalance. Main 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 really useful 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 and not using a human doctor ever reviewing the information.
The next 12 months, a class-action lawsuit accused UnitedHealth of deploying its AI device, often 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 manage prices.
Critics, like Shah, say these methods cut back sufferers to knowledge factors, prioritizing prices over ethics.
“Writing an enchantment letter can take eight hours between digging by way of billing codes, medical journals and citations,” Shah mentioned. “For the typical American, that is like a full-time job on high of all the pieces else they’re coping with.”
Sufferers 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, ultimately, life-altering care is delayed or deserted altogether.
Flipping the script
In opposition to this backdrop of rising denials and AI-automated gatekeeping, Counterforce Well being is positioning itself as a counterpunch, going lick for lick with huge medical health insurance firms deploying AI to disclaim claims. As an alternative of sufferers drowning in paperwork or giving up, the Counterforce platform arms them with the instruments to push again shortly and successfully.
“Proper now, insurers are utilizing AI to disclaim claims in seconds, whereas sufferers and medical doctors spend hours preventing again,” Shah mentioned. “That is not a good struggle. Our mission is to flip the script and make appeals as simple as one click on.”
When a denial letter is uploaded, Counterforce’s system would not simply produce boilerplate textual content; it analyzes the insurer’s rationale and attracts on medical analysis and different appeals which have succeeded beneath related circumstances. The objective is to create tailor-made, evidence-driven appeals which might be arduous for insurers to dismiss, whereas additionally saving sufferers and their households lots of of hours of analysis and drafting enchantment letters.
Many sufferers merely haven’t got the time, vitality or assets to struggle appeals. As Dr. David Casarett, a professor of drugs at Duke and part chief of palliative care at Duke Well being, advised CNET, some sufferers “step into the ring with boxing gloves on,” however many simply surrender, go into debt or forgo remedy altogether. Casarett works with CareYaya as a associate 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 vital remedy. As a result of she and her husband had superior scientific backgrounds, and a son with a medical diploma, they meticulously tracked appeals and sometimes received.
“Our appeals have been profitable,” he mentioned. “However what about all people else? What prayer does a single mother with two jobs and a highschool training have towards a multibillion-dollar insurance coverage trade?”
The group has expanded past its pilot program at Wilmington Well being’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 will in any other case have been out of attain.
Shah’s longer-term imaginative and prescient is for instruments like Counterforce to change into trusted, goal arbiters — the place sufferers and insurers acknowledge their appeals as legitimate, dependable and evidence-based.
Reducing the fee barrier with AI
When requested why particularly AI was chosen to be the go-to device, 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 College of Pennsylvania analysis middle creating AI and tech to assist getting older and independence.
Shah mentioned conserving this device accessible was a precedence to permit extra folks the chance to enchantment. Whereas there are alternatives to rent affected person advocates to evaluation 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 companies had reached $1,425 per particular person per 12 months by 2022.
Including a further $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 Individuals.
“Proper now, interesting is admittedly for the wealthy, or I might even say the ultra-rich,” Shah mentioned. “To unravel this drawback, [we had] to determine a technique to do it without cost or dust low cost as a result of folks haven’t got $300 to spend on a affected person advocate once they cannot afford the drugs they critically want. We thought AI could be the proper use case as a result of the continued price per consumer is actually pennies.”
For now, Shah mentioned Counterforce intends to stay free for people.
Methods to get began with Counterforce Well being
Earlier than starting with any service that collects delicate well being data, it’s best to all the time contemplate privateness. Counterforce Well being collects private and health-related knowledge — equivalent to your insurance coverage particulars, denial letters and medical background — to generate appeals. The company states that it doesn’t promote this data, makes use of encryption and different safeguards to guard it, and solely shares knowledge with trusted service suppliers or third events beneath confidentiality and authorized compliance necessities.
To get began with Counterforce Well being, you’ll be able to visit the homepage, click on “Begin Free Attraction” 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 completely drafted, editable enchantment able to submit.
