RTP startup uses AI to fight health insurance denials
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A Research Triangle Park startup wants to make appealing health insurance denials easier through a new artificial intelligence tool.
Why it matters: A growing number of startups are turning to new AI tools to help patients navigate complex policies and byzantine processes to appeal insurance denials, according to NBC News.
- The number of prescription drug claims denied by insurance grew by 25% between 2016 and 2023, according to the New York Times.
- And in 2023, Affordable Care Act insurers denied 20% of claims, Axios reported.
Driving the news: Enter Counterforce Health, a startup founded at the Frontier coworking campus in Research Triangle Park.
- The company's AI assistant drafts customized appeal letters that comb through a patient's policy, looking for the best line of defense, greatly reducing the amount of hours many patients spend drafting appeals.
- At the moment, few patients appeal denied claims at all, according to an analysis by KFF.
Zoom in: Neal Shah, a former hedge fund manager turned startup founder, has been trying to change the health care industry he has found frustrating for years, through a succession of startups run by a handful of employees in RTP.
- Shah, who left his job on Wall Street to move back to North Carolina to take care of sick family members, is the founder of CareYaya, an online platform that helps connect people looking for at-home care workers with students studying health care.
- That platform has taken off in the past three years, growing from hundreds of workers based at Triangle-area universities to thousands across the country.
Now, he's focused on expanding Counterforce Health, which he co-founded last year to provide free AI tools to patients and funding through several grant awards.
- The company's platform uses a variety of AI models to run its appeals process, pinging medical journals and insurance review commission data to make a case for why a patient's appeal should be granted.
- He views it as a way to counteract the algorithms that insurance companies use to deny claims. (Some insurance companies are currently being sued for using algorithms to deny claims, Axios previously reported.)
What they're saying: "You end up spending hours and hours researching, fighting on the phone and just stressing the hell out," Shah told Axios about the current appeals process. "And many people will be too intimidated and scared to do that."
- In some ways, it's become a battle of AI versus AI in the insurance world, Shah added, and if the patient doesn't have a tool, "you lose."
What's next: Right now, the Counterforce tools are free for patients and clinics to use. Some clinics are using the service, like Wilmington Health, to make it easier to draft appeals for its patients, and some pharmaceutical companies have begun reaching out to the team about the tools.
- Shah intends to keep Counterforce free for individual patients and punt on any monetization efforts until the platform's user base grows even more.
- But eventually, he believes it could monetize it by charging clinics and other companies for using it and leveraging the large database it is now building on insurance claims.