The unexpected way AI helps with health insurance denial appeals

For Neil Shah, the breaking point came during his wife’s cancer treatment.

He remembers being exhausted, surrounded by piles of hospital bills, denial notices and insurance statements. When he and his wife tallied everything — from monthly premiums and out-of-pocket costs to uncovered treatments — they realized the shocking truth that over the years, they might have been better off paying entirely out of pocket rather than having health insurance at all.

Initially, Shah attributed all the bills and denials to bad luck.

“Then I went down a rabbit hole, where I just tried to figure out what’s going on with health insurance?” He told CNET. “Why are there so many claim denials? How many people does this affect? ​​Then I became obsessed with it.”

This obsession and frustration became the seed Kariyayaa North Carolina-based company launched by Shah to connect college students entering the healthcare field with families in need of affordable care. But even as CareYaya grew, Shah continued to face the all-too-familiar situation of patients, caregivers and students being inundated with health insurance claim denials outright.

“I realized that I am not alone and the people who use CareYaya are not alone,” Shah said. “There are millions of Americans dealing with this problem. People are drowning in claims of denial.”

Last year, Shah launched another startup, Anti healthwhich offers a free platform that creates personalized insurance appeal letters in minutes.

The Counterforce platform allows patients or clinics to upload denial letters and related medical records. The system analyzes insurance policies, reviews medical literature, and leverages successful appeals to produce a draft response. Users can edit the message before sending it, but the AI ​​tool does the heavy lifting of translating dense healthcare policies, clinical arguments and organizing appeals.

With denials mounting across the country and debates growing about the ethical use of artificial intelligence, the company’s arrival comes at a pivotal moment. Health insurance companies are increasingly turning to artificial intelligence to review claims, leading to more denials and frustration for patients seeking help. Counterforce is trying to flip the script, using AI not to deny coverage but to help patients regain it.

Basically, AI fights AI.

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Denial increased nationwide

Denial of health insurance has become a defining feature of the American health care system. Patients are increasingly paying premiums, deductibles and copayments, only to find that insurance companies often refuse to cover treatments recommended by their doctors.

The numbers tell its tragic story.

According to data from KFF. 20% of all claims Via the Affordable Care Act Marketplace plans were denied in 2023. ACA plans covered more than 20 million Americans At the beginning of 2025. Audits have found that insurers wrongly deny or delay millions of care claims each year in the Medicare Advantage program, which covers more than 30 million Americans.

However, appeals remain rare. less than 1% The ACA plan denial is being appealed.

“Ninety-nine percent of patients or family caregivers do not appeal,” Shah said. “Of the small fraction that does, 40% win. This means that most people are intimidated, don’t know their rights or assume the rejection is final. This also shows how trivial a lot of these rejections are.”

In recent years, artificial intelligence has amplified this imbalance. Major insurance companies have turned to artificial intelligence tools that scan medical records, apply coverage rules, and generate denial letters in bulk. Investigations have found that some algorithms make near-instant denials, even when a provider has recommended care.

In 2022, ProPublica investigation It revealed that Cigna used an artificial intelligence-based algorithm to reject more than 30,000 claims in just two months, often without a human doctor reviewing the files.

The following year, Class action UnitedHealth has been accused of deploying its artificial intelligence tool, known as nH Predict, to prematurely cut off care for elderly Medicare patients, regardless of their doctors’ recommendations. That lawsuit was filed in 2023, a year before the killing of then-UnitedHealth CEO Brian Thompson, intensifying national scrutiny of how insurance giants use deniability to control costs.

Critics, like Shah, say these systems undercount patients in data points, prioritizing costs over ethics.

“Writing an appeal letter can take eight hours between researching billing codes, medical journals, and citations,” Shah said. “For the average American, this is like a full-time job on top of everything else they deal with.”

Patients are often forced into an unpleasant cycle when dealing with the healthcare system: claims are submitted, claims are denied by machines, appeals are buried, and, ultimately, life-changing care is delayed or foregone altogether.

Flipping the script

Against this backdrop of rising denials and automated gatekeeping using AI, Counterforce Health is positioning itself as a counterforce, aligning itself with major health insurers deploying AI to deny claims. Instead of patients drowning in paperwork or giving up, the Counterforce platform gives them the tools to respond quickly and effectively.

“Currently, insurance companies are using AI to deny claims in seconds, while patients and doctors spend hours responding,” Shah said. “This is not a fair fight. Our job is to flip the script and make appeals easy with one click.”

When a rejection letter is uploaded, the Counterforce system not only produces boilerplate text; It analyzes the insurer’s rationale and draws on clinical research and other appeals that have been successful under similar circumstances. The goal is to create personalized, evidence-based appeals that are difficult for insurance companies to reject, while saving patients and their families hundreds of hours of research and drafting of appeal letters.

Many patients simply do not have the time, energy or resources to face appeals. like Dr. David CassarettSome patients “step into the ring wearing boxing gloves,” but many give up, fall into debt or forego treatment altogether, the Duke University professor of medicine and chief of palliative care at Duke University Health told CNET. Casarett works with CareYaya as a physician partner.

Cassarett’s mother suffered from multiple myeloma, a cancer of the blood’s plasma cells, and faced repeated insurance denials for expensive but necessary medications. Because she and her husband had advanced scientific backgrounds and had a son with a medical degree, they meticulously pursued appeals and often won.

He added: “Our appeals were successful.” “But what about everyone else? What is the prayer of a single mother with two jobs and a high school education against the multi-billion dollar insurance industry?”

The organization has expanded beyond its pilot program at Wilmington Health’s rheumatology clinic in North Carolina to include clinics and hospitals across the United States, providing free access to patients and caregivers. Thousands of patients have used Counterforce’s tools to undo denials of treatments that would have otherwise been out of reach, Shah said.

Shah’s long-term vision is for tools like Counterforce to become objective and reliable arbitrators – where patients and insurers know their claims are valid, reliable and evidence-based.

Reducing the cost barrier using artificial intelligence

When asked why AI specifically was chosen as the tool of choice, cost was a big red flag. Counterforce is free to use due to funding from several grants and investments from project partners, including A $2.47 million grant from PennAITecha research center at the University of Pennsylvania that develops artificial intelligence and technology to support aging and independence.

Shah said keeping this tool accessible to everyone is a priority to allow more people the opportunity to appeal. While there are options to hire patient advocates to review denials and file appeals, they can be expensive, ranging from $80 to $150 per hour, depending on the attorney’s set rates.

According to the 2025 report From KFF, direct spending on health care services will average $1,425 per person per year by 2022.

Adding an additional $300 to $1,000 to hire help to write the appeal is likely not feasible for many low-income or middle-class Americans.

“Right now, the appeal is really directed at the rich, or even the super-rich,” Shah said. “To solve this problem, (we had to) figure out a way to do it for free or at low cost, because people don’t have $300 to spend on patient advocacy when they can’t afford the medication they desperately need. We thought AI would be the perfect use case because the ongoing cost per user is literally pennies.”

For now, Shah said Counterforce intends to remain free to individuals.

How to get started with Counterforce Health

Before starting any service that collects sensitive health information, you should always consider privacy. Counterforce Health collects personal and health-related data – such as your insurance details, denial letters, and medical background – to create appeals. The company states It does not sell this information, uses encryption and other safeguards to protect it, and only shares data with trusted service providers or third parties under confidentiality and legal compliance requirements.

To get started with Counterforce Health, you can Visit the home pageclick “Start Free Appeal” and you will be asked to fill out a brief questionnaire with information, such as the reason you are visiting the website and basic information about your insurance denial. From there, you’ll submit your rejection letter and insurance details, and the system’s AI will create a fully worded, editable resume ready to send.