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 all the things — from month-to-month premiums and out-of-pocket prices to uncovered therapies — they realized the surprising fact that through the years, they may have been higher off paying fully out of pocket than carrying medical insurance in any respect.

At first, Shah chalked all the 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 insurance?” he informed CNET. “Why are there so many denials of claims? How many individuals is it impacting? After which I simply acquired obsessive about it.”

That obsessiveness and frustration grew to become the seed for CareYaya, a North Carolina-based firm Shah launched to attach school college students coming into the well being care area with households in want of inexpensive caregiving. However at the same time as CareYaya grew, Shah stored encountering the all-too-familiar state of affairs of sufferers, caregivers and college students fully overwhelmed by medical insurance declare denials.

“I spotted I am not alone and the individuals utilizing CareYaya are usually not alone,” Shah mentioned. “There are tens of millions of People coping with this drawback. Individuals are drowning in denial claims.”

Final yr, Shah launched one other startup, Counterforce Health, which provides a free platform that generates custom-made 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 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. Well being 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. 

Basically, AI is preventing AI.

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Denials on the rise nationwide 

Medical health insurance denials have turn into a defining characteristic of the American well being care system. Sufferers pay rising premiums, deductibles and copays, solely to seek out that insurers usually refuse to cowl the therapies their medical doctors suggest.

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 at first of 2025. Audits have discovered that insurers wrongly deny or delay tens of millions of requests for care every year in Medicare Benefit, which covers greater than 30 million People. 

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 ultimate. And it additionally reveals how frivolous so many of those denials are.”

In recent times, 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 helpful 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, usually with no human doctor ever reviewing the information. 

The next yr, a class-action lawsuit accused UnitedHealth of deploying its AI software, 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 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 methods cut back sufferers to knowledge factors, prioritizing prices over ethics. 

“Writing an enchantment letter can take eight hours between digging by billing codes, medical journals and citations,” Shah mentioned. “For the common American, that is like a full-time job on prime of all the things 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, finally, life-altering care is delayed or deserted altogether.

Flipping the script

Towards this backdrop of rising denials and AI-automated gatekeeping, Counterforce Well being is positioning itself as a counterpunch, going lick for lick with large medical insurance corporations 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 rapidly 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 combat. 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 underneath related circumstances. The objective is to create tailor-made, evidence-driven appeals which are exhausting 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, power or sources to combat appeals. As Dr. David Casarett, a professor of drugs at Duke and part chief of palliative care at Duke Well being, informed CNET, some sufferers “step into the ring with boxing gloves on,” however many simply hand over, go into debt or forgo therapy altogether. Casarett works with CareYaya as a companion 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 expensive but mandatory treatment. As a result of she and her husband had superior scientific backgrounds, and a son with a medical diploma, they meticulously tracked appeals and infrequently gained. 

“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 hundreds of sufferers have used Counterforce’s instruments to overturn denials for therapies that will 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.

Decreasing the price barrier with AI

When requested why particularly AI was chosen to be the go-to software, price 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 College of Pennsylvania analysis middle creating AI and tech to help getting old and independence.

Shah mentioned holding this software accessible was a precedence to permit extra individuals the chance to enchantment. Whereas there are alternatives to rent affected person advocates to evaluate denials and kind appeals, they are often expensive, starting from $80 to $150 per hour, relying on the advocate’s set charges. 

According to a 2025 report from KFF, the common out-of-pocket spending for well being care companies had reached $1,425 per individual per yr 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 People. 

“Proper now, interesting is actually for the wealthy, or I’d even say the ultra-rich,” Shah mentioned. “To resolve this drawback, [we had] to determine a solution to do it totally free or filth low-cost as a result of individuals do not have $300 to spend on a affected person advocate after they cannot afford the medication they critically want. We thought AI could be the right use case as a result of the continued price per person is actually pennies.”

For now, Shah mentioned Counterforce intends to stay free for people.

Learn how to get began with Counterforce Well being

Earlier than starting with any service that collects delicate well being info, you need to all the time think about privateness. Counterforce Well being collects private and health-related knowledge — comparable to your insurance coverage particulars, denial letters and medical background — to generate appeals. The company states that it doesn’t promote this info, makes use of encryption and different safeguards to guard it, and solely shares knowledge with trusted service suppliers or third events underneath confidentiality and authorized compliance necessities.

To get began with Counterforce Well being, you may visit the homepage, click on “Begin Free Attraction” and you will be prompted to fill out a quick questionnaire of knowledge, comparable 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.