For Neal Shah, the breaking point came during his wife's cancer treatment.
He remembers being overwhelmed, surrounded by stacks 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 than carrying health insurance at all.
At first, Shah chalked all of the bills and denials up to bad luck.
"Then, I went down a rabbit hole of research, of just trying to figure out what is going on with health insurance?" he told 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/CNET
That obsessiveness and frustration became the seed for CareYaya, a North Carolina-based company Shah launched to connect college students entering the health care field with families in need of affordable caregiving. But even as CareYaya grew, Shah kept encountering the all-too-familiar situation of patients, caregivers and students completely overwhelmed by health insurance claim denials.
"I realized I'm not alone and the people using CareYaya are not alone," Shah said. "There are millions of Americans dealing with this problem. People are drowning in denial claims."
Last year, Shah launched another startup, Counterforce Health, which offers a free platform that generates customized insurance appeal letters in minutes.
Counterforce's platform allows patients or clinics to upload denial letters and relevant medical records. The system analyzes insurance policies, reviews medical literature and draws from successful appeals to produce a draft response. Users can edit the letter before submitting it, but the AI tool does the heavy lifting of translating dense health care policies and clinical arguments and structuring an appeal.
As denials climb nationwide and debates about ethical AI use ramp up, the company's arrival comes at a pivotal moment. Health insurers are increasingly turning to AI to review claims, which is resulting in more denials and frustration for patients seeking help. Counterforce is trying to flip the script, using AI not to block coverage but to help patients win it back.
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