Rising Denials
According to The New York Times, prescription drug claim denials grew by 25% between 2016 and 2023. In 2023, insurers on the Affordable Care Act marketplace denied 20% of all claims, Axios reported. Despite the high rate of denials, research from KFF shows that few patients ever file an appeal, often due to the complexity and time required.
The Startup: Counterforce Health
Counterforce Health, founded at the Frontier coworking campus in RTP, created an AI assistant designed to draft customized appeal letters. The tool reviews a patient’s insurance policy and identifies potential arguments to strengthen an appeal, reducing the time and effort required by patients and clinics.
Neal Shah, Counterforce’s co-founder, has a background in finance and healthcare startups. After leaving Wall Street to return to North Carolina to care for family members, Shah launched CareYaya, a platform connecting healthcare students with families seeking at-home caregivers. CareYaya has grown from a local service in the Triangle to a network of thousands nationwide in just three years.
Building on that experience, Shah co-founded Counterforce Health in 2023. The company has received several grant awards to expand its services and continues to provide its tools free of charge to patients.
How It Works
Counterforce Health’s platform uses multiple AI models to process appeals. The system draws on insurance review commission data and medical journals to support claims. By automating this research and drafting process, the tool is designed to lower barriers for patients who may otherwise avoid filing appeals altogether.
Some insurance companies have faced lawsuits over their own use of algorithms to deny claims, according to Axios. Shah describes the current environment as “AI versus AI,” with patients needing similar tools to avoid being at a disadvantage.
Adoption and Next Steps
Several clinics, including Wilmington Health, are already using Counterforce Health’s platform to support patients. Pharmaceutical companies have also expressed interest in its capabilities.
The service remains free to patients and clinics for now. Shah has stated that any monetization will come later, potentially through charging clinics or companies that use the platform and by leveraging the database of insurance claim data the system is building.
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