Fighting back against claim denials: How AI can empower physicians and patients

I never imagined that battling a $32,000 health insurance claim denial would lead me deep into America’s health care system, fighting insurance companies. My background is in finance and technology, not medicine. But when my wife was diagnosed with cancer, I became her advocate, navigating endless insurance appeals just to get the care she needed.

That experience opened my eyes to a growing crisis: patients and doctors drowning in insurance claim denials. Across the country, claim denials are skyrocketing, creating a massive burden on medical practices.

A growing crisis for physicians and patients

Hundreds of millions of claims — ranging from office visits to life-saving treatments — are denied yearly. A recent survey found that 75% of health care providers report increasing denial rates. If you feel like you’re doing more paperwork and getting fewer payments, you’re not alone.

Denied claims hit practice finances hard. In fact, out of roughly $3 trillion in claims submitted annually, about $262 billion worth are initially denied. For an average practice, that could mean hundreds of thousands of dollars at risk — funds meant to support patient care, staff salaries, and medical equipment.

Beyond revenue loss, denials waste time. Physicians and staff spend 10 or more hours weekly fighting insurers — hours stolen from patient care. We’ve turned providers into insurance negotiators. No doctor went to medical school to battle insurance companies, yet that’s the reality today.

Patients feel the pain, too. A denied claim can mean a surprise bill or delayed treatment. Most patients don’t appeal denials — only 1% do — yet over half of those who appeal win. This means insurers often reject claims they know won’t hold up under scrutiny.

Why are claim denials increasing?

Insurers increasingly use artificial intelligence (AI) to reject claims automatically. A minor documentation issue — a wrong code, a missing pre-authorization — can trigger instant denials. One investigation found an insurer’s algorithm denied thousands of claims in seconds, with physicians signing off without reviewing patient charts.

Insurance policies are also constantly shifting. Payers introduce new rules, prior authorization requirements, and coding edits, forcing providers to hit a moving target. A major insurer recently began requiring extra documentation for certain visits, leading to a wave of unexpected denials. Many practices didn’t find out until payments stopped.

This creates an adversarial environment where insurers use denials as a financial lever. At stake isn’t just money, but the integrity of health care and patient trust. If every doctor’s visit can become a billing dispute, confidence in the system erodes.

Fighting back with AI-powered solutions

How do we push back? Policy reform is crucial, but change is slow. Meanwhile, we need immediate relief. The answer? Using AI to fight denials at scale.

If insurers use AI to deny claims, we can use AI to challenge them. Advanced automation can streamline appeals, turning the tables on payers. AI-powered tools can analyze medical records, identify missing details, and draft expert-level appeal letters citing clinical guidelines and insurer policies.

At Counterforce Health, we’ve built an AI-driven platform that does exactly this. Our system:

• Analyzes denied claims and identifies the precise reason for rejection.
• Cross-references medical guidelines and patient history.
• Auto-generates compelling appeal letters in minutes, not hours.
• Reduces staff workload while increasing successful appeals.

For example, if an insurer denies a plasma exchange for myasthenia gravis as “not medically necessary,” our AI instantly pulls national neurology guidelines, highlights relevant patient history, and crafts an appeal proving the treatment is standard care. Physicians can focus on medicine instead of paperwork.

But writing appeal letters is only half the battle. Practices also waste time following up — calling insurers, navigating phone trees, and verifying claim statuses. We’ve trained an AI-powered voice agent, “Maxwell,” to handle these tedious tasks. Maxwell checks appeal statuses, follows up persistently, and ensures insurers don’t drag their feet.

Results that matter

Clinics using AI-powered appeals report:

• 10x more appeals filed with no added admin burden.
• Faster approvals improving cash flow.
• Fewer write-offs as denials are successfully overturned.
• Less staff burnout with AI handling repetitive tasks.

One practice administrator told me that appealing nearly all denials with AI “finally leveled the playing field.” Before, they let small denials go because appeals cost more than the claim. Now, no denial goes unchallenged, forcing insurers to reconsider automatic rejections.

Leveling the playing field in health care

Technology isn’t a cure-all. We still need insurance reform, trained billing staff, and savvy practice managers. But AI is a powerful force multiplier, automating grunt work so doctors and staff can focus on patient care.

By challenging denials at scale, AI pressures insurers to act more fairly. If every rejection is met with a swift, well-supported appeal, payers may rethink blanket denials. This “AI arms race” could lead to fewer inappropriate denials and faster resolutions — benefiting everyone.

Taking back control

Claim denials don’t have to be an unavoidable cost of doing business. Just as we embrace cutting-edge clinical tools, we can leverage AI to reclaim revenue and reduce administrative headaches.

What started as my personal battle against an unjust claim denial has become a mission: empowering physicians to fight bureaucracy efficiently. AI-driven solutions aren’t about surrendering to technology — they’re about using it to serve our goals.

The endgame isn’t just winning appeals — it’s ensuring patients receive care and practices receive fair compensation, without undue burden. Every minute and dollar reclaimed from insurers is a minute and dollar invested back into patient care.

It’s time to turn the tables. With smart policy changes and AI-driven solutions, we can move from a “claim denied” culture to a “caim fairly reviewed” system. I’ll continue working on tools to support physicians and patients in this fight, so we don’t let rising denials define the future of health care. Instead, we innovate, advocate, and restore balance — because when we reduce the friction of fighting insurers, we can refocus on what matters: caring for patients.

Neal K. Shah is the chairman of Counterforce Health, a leading AI platform for helping patients fight health insurance claim denials, by analyzing success patterns across similar cases and using evidence-based strategies. He also serves as CEO of CareYaya Health Technologies, one of LinkedIn’s Top 50 Startups in America in 2024, which runs an AI-powered technology platform that helps thousands of families with health care across America. He is a Top Healthcare Voice on LinkedIn with a 70k+ following, and has been a featured contributor for CNBC, Wall Street Journal, Barron’s and TechCrunch.