Taking on America’s Health Insurance Bureaucracy with AI

Neal K. Shah

(Credit: CareYaya Health Technologies)

I never expected a battle with health insurance companies over a $32,000 denied claim would lead to creating technology to help medical practices fight back. For healthcare providers, these battles are all too familiar.

Neurology practices face some of the highest denial rates in medicine.¹ Insurance companies routinely reject claims for essential treatments, from multiple sclerosis medications to post-stroke rehabilitation services. The complexity of neurological care makes it particularly vulnerable to denials, creating an overwhelming administrative burden that takes valuable time away from patient care.

(Credit: American Hospital Association, “Payer Denial Tactics – How to Confront a $20 Billion Problem”)

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Denials management is a time-consuming task, with providers spending over 10 hours weekly wrestling with insurance companies over denied claims. Each denial costs on average $43 to process.² For complex cases requiring multiple rounds of prior authorization, the staff time and financial drain become unsustainable. Nationwide, this administrative waste tops $19 billion annually – money that should fund patient care.³

Insurance companies deploy artificial intelligence to automate claim rejections, hitting neurology practices especially hard. AI systems flag ongoing treatment plans for denial without considering individual medical necessity or the progressive nature of many neurological conditions. Even Medicare Advantage plans meant to help older adults frequently deny neurological care, with MRIs and CT scans being some of the highest reported for denial.⁴

That's why we launched Counterforce Health. Our AI-powered platform helps neurology practices fight back efficiently. The AI system generates customized appeal letters based on your documentation, guides staff and patients through the appeals process, and even handles insurance company phone calls through voice AI agents. Early users report saving 8-10 hours weekly on administrative tasks while increasing rates of successful appeals. Insurance denial rates have jumped in recent years, increasing the administrative burden for providers and worsening the patient experience of healthcare. Counterforce Health is a novel approach to revenue cycle management for providers that can also improve the patient experience.

(Credit: The Boston Globe, ValuePenguin)

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For example, when insurers deny coverage for plasma exchange treatments in patients with myasthenia gravis⁵ or reject authorized medication refills for patients with epilepsy⁶, the AI system can rapidly generate evidence-based appeals citing current clinical guidelines. Then, an AI phone agent can handle routine follow-up calls to insurers, freeing staff to focus on patient care. Federal audits reveal that many denials stem from insurers demanding unnecessary documentation that’s already present in case files, or imposing clinical criteria more restrictive than Medicare’s own rules.

Some will argue that insurance companies help control healthcare costs. But just look at the skyrocketing costs of health insurance facing individuals across America.

(Credit: CBS News, KFF.)

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Providers like you know the reality – that denial strategies often target legitimate, necessary care while massively ballooning administrative overhead. For conditions requiring timely intervention, these delays can significantly impact patient outcomes. And for post-care denials, it unwittingly turns the healthcare provider into a bill collector, damaging the patient-provider relationship that is at the heart of healthcare.

The system is broken, and we need more technological innovation and systemic reform. With the growing demand for neurological care driven by our aging population, there needs to be a better way for providers and patients to stand up to the health insurance bureaucracy. Tools like these can help level the playing field today, allowing practices to focus on patient care rather than paperwork. Through AI innovation, we can equip neurology practices with the same technological capabilities that insurance giants are using against them.

No provider should spend more time fighting insurance companies than treating patients. With the right tools, you don't have to. It's time to put advanced technology to work for neurology practices.

REFERENCES
1. Becker’s ASC Review, “Which physicians have the most claims denied, resubmitted? A specialty breakdown.” Published on May 21, 2020. Accessed Jan 28, 2025. https://www.beckersasc.com/asc-coding-billing-and-collections/which-physicians-have-the-most-claims-denied-resubmitted-a-specialty-breakdown.html
2. Medscape, “Why Insurers Keep Denying Claims (And What To Do)”. Published December 18, 2024. Accessed January 28, 2025. https://www.medscape.com/viewarticle/why-insurers-keep-denying-claims-and-what-do-2024a1000ndb?form=fpf
3. American Hospital Association, “Payer Denial Tactics – How to Confront a $20 Billion Problem”. Accessed January 28, 2025. https://www.aha.org/aha-center-health-innovation-market-scan/2024-04-02-payer-denial-tactics-how-confront-20-billion-problem
4. JAMA Health Forum, “Federal Investigators Find Medicare Advantage Plans Too Often Deny, Delay Needed Care”. Published May 10, 2022. Accessed January 28, 2025. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2792414
5. Center for the Evaluation of Value and Risk in Health, Tufts Medical Center. “How might US health plans cover efgartigimod for generalized myasthenia gravis? Lessons from the SPEC database.” Published November 4, 2021. Accessed January 28, 2025. https://cevr.tuftsmedicalcenter.org/news/2021/how-might-us-health-plans-cover-efgartigimod-for-generalized-myasthenia-gravis-lessons-from-the-spec-database
6. CDC Morbidity and Mortality Weekly Report. “Barriers to and Disparities in Access to Health Care Among Adults Aged >= 18 Years with Epilepsy - United States, 2015 and 2017”. Published May 27, 2022. Accessed January 28, 2025. https://www.cdc.gov/mmwr/volumes/71/wr/mm7121a1.htm

Neal K. Shah is the Chairman of Counterforce Health and CEO of CareYaya Health Technologies, one of LinkedIn’s 2024 Top 50 Startups in America. He runs an AI-powered technology platform that helps thousands of families with healthcare across America. Shah has advanced AI projects to improve neurological care with support from the National Institutes of Health, Johns Hopkins AITC and Harvard Innovation Labs. He is a “Top Healthcare Voice” on LinkedIn with a 65k+ following, and has been a featured contributor for CNBC, Wall Street Journal, Barron’s and TechCrunch.