AI Declares War on Denials with Neal Shah | ShiftShapers Podcast

In this episode of ShiftShapers, host David A. Saltzman sits down with Neal Shah, co-founder of Counterforce Health, to explore how artificial intelligence is transforming the fight against denied health insurance claims. Shah shares his personal journey from finance into healthcare advocacy, shaped by firsthand experiences navigating the broken healthcare system for his family. That path ultimately led to the creation of Counterforce Health—a free AI-powered platform that’s helping patients and small clinics appeal insurance claim denials with unprecedented efficiency. With millions of claims denied each year—and most never appealed—Shah explains why automation is the key to leveling the playing field and giving patients back their voice. He also introduces Maxwell, Counterforce’s next-gen AI assistant, and previews the platform’s expanding capabilities for tackling insurers head-on. 🤖 Sponsored by BenePower BenePower is an AI-powered platform helping advisors build high-impact, self-insured health plans quickly and seamlessly. By integrating best-in-class point solutions and eliminating inefficiencies, BenePower reduces costs, improves member outcomes, and positions advisors as industry leaders. 🔗 Learn more at BenePower.com 🔑 Key Takeaways from This Episode Why 450 Million Claims Get Denied—and Go Unchallenged Despite the high success rate of appeals, fewer than 2% of denied claims are contested. Shah explains how complexity, red tape, and lack of awareness keep patients and providers from fighting back. From Wall Street to Healthcare Warrior Shah’s journey from finance to elder care—and ultimately to launching a mission-driven tech company—reveals how personal pain points can inspire powerful innovation. How Counterforce Health Uses AI to Automate Appeals The platform generates detailed appeal letters using legal precedents, medical journals, and historical data—empowering users to overturn denials without legal or medical expertise. A 70% Win Rate That’s Beating the Odds While national appeal success rates hover around 40–50%, Counterforce Health is seeing over 70% success—thanks to smart automation and a deep understanding of insurer tactics. Introducing “Maxwell”: AI That Talks Back to Insurers Neal reveals a sneak peek at Maxwell, an AI-powered voice assistant designed to handle phone calls with insurance companies—reducing workload and stress for patients, caregivers, and providers.

 
450 million claims are denied each year
but fewer than 2% are ever appealed And
though the majority of those appeal
denials are overturned only 2% are ever
appealed What's up with that And what
can be done to even up the odds We'll
find out on this episode of Shift
Shapers
Change either energizes or paralyzes The
choice is yours This is the Shift
Shapers podcast bringing the employee
benefits industry interviews with
individuals and companies who are
shaping the industry shifts And now
here's your host David Saltzman
To help us answer that question we've
invited Neil Shaw chairman and
co-founder of a new company that's
looking to solve that problem or help
consumers solve that problem called
Counterforce Health Welcome Neil
Thanks for having me David It's It's our
pleasure Let We always like to start out
talking about what your journey is How
do you get to be doing what you're doing
Because almost nobody's got a straight
line Like nobody woke up one morning in
their crib and said "I want to be in the
insurance business." How did you get
here Yeah sure So I actually have a
completely squiggly line to get here Um
most recently I have actually been
running one of the largest and fastest
growing elder care platforms in America
called Keraya Health Technologies Uh
we're caring for thousands of older
adults across the country many of whom
are living with dementia And then to
give you kind of like the full backstory
um you know most of my career up until
my mid-30s I was in the finance business
and I was a hedge fund manager Um I
actually experienced a um tremendous uh
care needs within my own family starting
in my early 30s of taking care of my
grandfather through dementia kidney
failure cancer and serious illness and
then end of life care where I really
coordinated a lot of the care but really
my mom left her career to be his
full-time caregiver and at that point
really opened my eyes to how broken kind
of our healthcare and homeare industry
is in the country Um and and then I
became kind of obsessed with the care
economy broadly speaking and the patient
experience and the family caregiver
experience Um and at that time I was
still like very focused on running my
fund I I'd worked really hard all my 20s
and 30s and I'd become a partner at a
multi-billion dollar fund and then I'd
been fortunate enough to have one of
those investors back me and I was
running my own $250 million fund Um so I
wasn't prepared to kind of like leave to
do this But then at the peak of my fund
uh in my mid-30s my wife became severely
ill and went through years of a cancer
battle Um and at that point I um kept
taking several sbaticals from running my
fund to be her full-time caregiver Um
and ultimately I actually had to make
the difficult decision to wind wind down
my fund um to become a full-time
caregiver for a couple years Um because
I thought it would make a huge impact on
her ultimate outcome in recovery Um
which you know knock on wood it did You
know she's now been in remission for a
few years Um and I think that's in no
small part to just managing her care
very uh closely Um and at that point you
know I left behind my finance career and
um decided to start a care company You
know I thought that the home care market
in the country was really broken Um I
wanted to make innovations to improve it
And so I started Kerrya which has now
become one of the fastest growing
startups Um helping uh care for people
in their homes and connecting them with
great caregivers who are all college
students go into the healthcare field We
did that and then that whole journey and
and and really seeing what my experience
was and my wife's experience was as a
patient with the system and how many
times we fought denied health insurance
claims for legitimate you know
treatments and procedures and
medications that were needed during a
difficult and dark journey of cancer and
then in three years of running Kerry and
seeing how many uh people varying
illnesses you know starting with
dementia um terminal cancer um you know
kind many other um chronic uh conditions
are facing this kind of like insurance
battle them and their family caregivers
I think that really um inspired me in
recent months to start counterforce
health You know I thought that there was
a huge gap in the market um nothing
built to improve the patient experience
um as well as uh geared towards small
clinics um and I thought that there's a
huge opportunity So that's been kind of
like it's been really um you know
personal journey and then also recently
a professional journey um of seeing just
where there are gaps in the market It's
unsurprising how many entrepreneurs get
into trying to solve a problem because
they've experienced it themselves Um
with all due respect to Simon Synynic I
don't think a lot of people start with
why I think they find their why but I
think they start with why not
You know why isn't there a way to solve
this problem Why isn't there a way to do
this easier And and just for our
listeners and and viewers on on YouTube
we will do a second interview with Neil
all about Kya but that's c a
rea.org Correct Yes that's right Okay If
you want to go you know get a jump on
our podcast If not we'll be talking to
Neil again soon about about that But
today we're talking all about
counterforce health And when we first
talked about this Neil one of the things
you did was you use an analogy of a
restaurant and meals and whatnot Can you
share that with the audience
Yeah I I wrote an article about it
recently you know that I kind of put out
on LinkedIn Pulse of you know can you
imagine if somebody sells you a
subscription that you can eat at a
restaurant or other restaurants twice a
week for a year and you know pay me a
couple thousand bucks a year and you can
enjoy this privilege and then you show
up and they're like "Oh actually no you
can't eat today." Like "Do you actually
need food Oh we're only serving this and
this." you know and I think that's kind
of like that's been the real you know
kind of like people really need to
distill what health insurance is to kind
of um you know other analogies of things
they might use in life like subscription
services for food subscription services
for meal delivery where if you pay
upfront and then when you go to
capitalize on like okay I need this and
you don't get it that's basically what I
think modern American health insurance
has kind of turned into um especially
during moments of extreme duress that
people are under whether it's um they're
managing care for a mother or father
through dementia or they're managing
care for a spouse through cancer you
know these are not situations where you
want to deal with financial stress and
existential stress of like am I going to
be able to get this you know that's why
you're paying you know during good times
you're paying so during bad times you
can kind of have the coverage and I
think then people are really shocked
that they can't get it when they need it
Well because you know as we've said
frequently on the program there's only
three things you can do with risk You
can keep it you can take it you can
share it rather or you can give it away
And you know to a certain extent you
expect that you've given it away and you
shouldn't have to deal with all this
nonsense on the back end So we talked a
little bit about the number of claims
that are denied
450 million claims Is that claims like
of all of all types Of all types Yeah I
mean I think basically the statistic
from the American Hospital Association
is that one in five American adults with
health insurance have had a denied claim
within the last year Right Shocking I
think the other interesting statistic is
that about 10 to 15 years ago the
average denial rates at many large
insurers were less than 2% and now
they've turned into anywhere from 15 to
25% And you know that was kind of Kaiser
Family Foundation had put out a detailed
research report on it So it's it's that
a lot of people are experiencing this
issue Um and the issue has gotten
notably worse in the last 5 to 10 years
The third interesting statistic is that
when they surveyed physicians um as
recently as 2022 something like 23% of
physicians said claims denials are a
major problem for me And then from 2022
to 2024 when the survey was done now 74%
of p uh physicians are saying claims
denialis has become a big problem So
this has been growing kind of throughout
the 2010s and the early 2020s which I
have a theory on that you know related
to kind of Obamacare and a variety of
other things but it has skyrocketed in
the last 3 years and I believe that is
fully on the part of AI and
weaponization of AI by health insurance
companies and asymmetric warfare you
know where patients and providers that's
going on with United Healthcare and you
know they're they kind of in the front
of that but there are others as well So
I'm interested You mentioned that you
have a theory about why this has
skyrocketed Would you share that with us
Yeah sure I mean I think the theory is
multiffold One I think Obamacare while
it may have been a well-intentioned
policy to get more people covered in
reality it became a big kind of boost to
private health insurance and really
forprofit health insurance right like
getting a lot more people on insurance
plans combined with a relatively lax
approach to regulation and specifically
antirust and mergers created this kind
of like monster uh and if you kind of
think about like you know you many many
times you may think who really benefited
from Obamacare and you can say yes you
could say sure people who didn't have
coverage before or whatever but if you
look back at the policy 15 years it's
almost like United Healthcare could have
written that policy because how did they
benefit twofold one they got a lot of
customers They got kind of risk covered
where government paid them out if there
was too much risk You forced people to
buy private health insurance for profit
And then you allowed a series of mergers
with no check or regulation So these
guys could not only gobble up other
insurers but kind of go and vertically
integrated and buy up PBMs and other
parts of the healthcare value chain and
buy even buy up physician practices So I
think that that Obamacare was kind of
like the start of it in my opinion of
like you can see insurance claim denial
rates and how the insurance industry is
operating because it's been around since
whatever 60 plus years before but
starting in the early 2010s the which is
just happen to be coincidental with when
Obamacare passes the behavior starts
going a little bit off you know
offkilter right where it's like okay
denial rates start rising then mergers
start happening like crazy and then now
you have it where like you know between
a handful of you know four or five guys
you know United Humanana Sigma whatever
they effectively control the market Um
you know you don't have a lot of choice
and depending on what employer you are
or what state you're in sometimes you're
limited to a handful of choices So
market share concentration has gotten
absurd Then many of them have vertically
integrated in other parts of the
healthcare value chain So you know
they're kind of like flexing power on
even what physicians are able to do what
pharmacies are able to do etc So I think
that it has been like really a complete
regulatory and market failure that's
resulted in this kind of like almost
like I wouldn't even call this
capitalism Like I'm I'm a hardcore
capitalist but like capitalist in the
sense of free markets and competition I
would consider this almost like crony
capitalism where a handful of mega
companies are kind of taking part of the
regulatory infrastructure to then flex
market power and then keep competition
out and then also have no responsibility
to consumer um who is the ultimate end
buyer and then using a government as a
way to force people into their product
Um so yeah I mean I think it's an
absolute disaster Um so I I mean I think
and and it's bipartisan right I mean I
think it's not Democrat or Republican I
think there have been tons of
administrations uh obviously not just at
the presidential level but even you know
uh people in Senate and Congress you
know kind of like thinking about what to
do about insurance But yeah I think it's
been a bipartisan complete disaster Um
and I think that's going to have to
change
Interesting I I I wish I could disagree
with you but I unfortunately can't And
I've been I've been around this for 40
plus years And I've done I I mean I've
run TPA I've paid claims Um I I I see
the correlation and and causation both
And it's it's frightening because if you
take this out on a on a line where are
we going to end up And is something just
going to implode as we go along But
let's let's get back to counterforce Um
so
You saw this problem up up close and
personal especially with your wife's
struggle and you decided okay there's
got to be a better way to get people to
easily appeal claims What is
counterforce do Is it aimed at the
patient or the physician or both How
give us a little background And I know
you're using AI to for to craft the
solution So tell us a little bit about
that Yeah sure So I think I think you
started the um interview with kind of
like the statistic that I thought was
like you know the the most capturing
right So like less than a few% of people
appeal claims right So there's so many
denied claims across America You know in
the hundreds of millions something like
49 million individuals have had a claim
denied within the last year And
depending on which stat you read it's
like some people say 2% some people say
1% uh that actually bother appealing So
vast majority of people are not
appealing If you kind of get into the
reasons why it's really 70% of people
don't fully know their appeal rights So
they don't know they can do it or how to
do it things like that um 40% of people
say they're too intimidated or lack the
time or the resources or expertise to do
it So you know and and of course there's
an overlap like 70 plus 40 is more than
100 right So some don't know how to do
it and some of those are also um I don't
know who to get for help So we kind of
thought there was two things you could
do here You know you could do mass
public awareness combined with tools to
make it as easy as possible or oneclick
as possible So what is the current
appeal process like for most people
Let's say at the 70% of the people are
like "I don't know how to do it I'm too
scared." For the people that do know how
to do it are like "Okay I can try." You
know I feel like you need to have a
doctor in your family to sit down and do
hours and hours of research You know to
fix you know billing codes are 24% of um
denied claims are because incorrect
billing code Another 40% are due to
medical necessity So billing codes are
something that you could look up in
billing code databases fix yourself
right That's something theoretically the
insurance company should you know
theoretically maybe even fix for you But
you know it's a maybe a frivolous reason
to deny So that is something where if
you had a doctor in your family you
could do it If you had the time and the
bandwidth you can go search databases
You can use AI yourself But most people
are intimidated They won't do it
Especially most people who are like less
affluent maybe less educated in more
rural areas They're going to be like I
don't know how to navigate this stuff
Right So there's a health and a tech
literacy component to that of why people
aren't appealing And then it happens
that those are probably the people who
can least afford to have the thing
denied Um so that's a perfect use case
for somebody doing it for them And then
medical necessity that's one where you
have to kind of go get doctors to
detailed site why something is needed Um
you know pull references from medical
journals or other cases and say this
treatment is needed for XYZ And that's
another thing where most kind of lay
people will be like I lack the expertise
to So over the last several months we
built a set of AI tools training them on
a lot of databases of seeing what
successful appeals have worked which
things have even gone to independent
review which have worked um even
training it on legal databases of that
have things all the way gone to court
and then learned uh successful appeal
strategies and been able to real time
access journals and uh medical
literature databases as well as billing
code databases to say for any person who
comes in whether in a rural area urban
area uneducated person minimally
educated or super well educated you know
you could even be doctor yourself come
into Counterforce Health and upload your
policy documents
upload your denial letter upload any
relevant information and just one click
and sit there and in less than 2 minutes
a super detailed well-crafted 8 plus
pages appeal letters with detailed
citations will be done for you um at no
cost Yeah we run it completely for free
by the way It's a social mission You
know I really just wanted to offer it to
individuals for free So you know that I
think can't be beat Um I think a lot of
individuals even if they had a a brother
that's a doctor might still have their
brother take you know 6 hours 10 hours
to write something like that and we can
do it uh with AI in a matter of you know
seconds um it having trained on tons and
tons of databases absorb really good
information and then to your point about
who the users are believe it or not
clinics are also using it and there
ultimately that'll be the path to
sustainability is that we find many
clinics especially small practices you
know we don't kind of like initially
start and gear towards big hospitals I
think a lot of them are trying to do
this stuff inhouse and good for them You
know they need to be but there's many
you know we have a rheatologist you know
it's two doctors running a small
practice here in a small town in North
Carolina and they see tons of patients
and they're averaging something like 35
to 40 denials per week And they have one
administrative person that handles kind
of scheduling billing payments etc And
then whenever she has time she will
write a few appeal letters And you know
I was talking to her you know a couple
weeks ago and she was like "Yeah I
typically will write maybe three four
letters if I can per week You know it
takes me a couple hours each It's a lot
of work." And she you know she has a
full-time job doing other stuff This is
an example where they started coming to
Counter Force Health Now she's writing
40 appeal letters a week you know kind
of like this And she would say they're
better than what she was writing by
herself because they're much more
detailed and and you know kind of much
better cited So I think that's really
kind of the power of AI really believe
that democratizing access to this you
know it's like if the insurers have
weaponized AI it's now time to provide
individual patients and small clinics
the same weapon to fight back Um because
I think it's been asymmetric warfare
until
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Ben Power And now back to our
conversation I know you guys are early
in the process Are you keeping stats
with users Are you asking them for
feedback on what the percentage of
claims that get denied or are overturned
when they use the system Yes Yeah Yeah
So uh we're keeping stats and so far
it's like surprisingly good Now there
might be like an average selection bias
where like people who are more intending
to fight come to the thing Um but on
average um it's averaging over 70% like
72% as of last stat which is like
surprisingly good I think average appeal
you know average appeal win rates in the
country depending on which stat you look
at are somewhere like 40 to 50% So
there's already kind of an incentive of
if you simply bother to write a letter
even if you don't use counterforce
health write it yourself do whatever
right Use chat GPT I don't care just
bother doing an appeal you'll win 40 to
50% of the time Then the better the
appeal letter is the more you'll win So
yeah like it's really cool to see 70%
plus win rate I mean that's that's
unbelievable right And it's like billing
code error related appeals I mean those
are extremely extremely easy to fix and
address And there it's just a matter of
taking the time to do it Medically
necessary a little bit harder In many
cases it just won't be done but again
easy enough to address And then there's
sometimes back and forth But what we
find in many situations is that people
just due to inertia intimidation were
just simply not bothering to do it Um
and then postcare denials are even I
mean I think those are you know uh
terrible right like where people have
these $100 bills $200 bills where
insurers just like frivolously denying
and most people are like I'll just pay
it out You know I was actually I was
talking to a lady actually that we
helped through our care platform um
living with a metastatic breast cancer
in her mid70s and she's been you know
taking this one routine med for the last
couple years 50 bucks a month um and it
got denied And this is before she knew
about counterforce and she just paid it
And I was like why'd you pay that Like
why didn't you bother And she's like
well she's like calculated And she's
like yeah the stress of writing a letter
the stress of researching you know
fighting She's like I just don't want to
deal with all that I'm already going
through cancer I'm thinking about how
much longer I got So she just kind of
said it's easier to pay the 50 bucks So
it's like those things in my opinion
that should be a close to 100% win rate
you know because in in in my opinion
these are just frivolous denials that
insurers are doing to see if they can
get away with it and just pocket the
money Um but people don't have tools If
you had a thing that spits out a letter
in one minute then sure that's worth 50
bucks of your time So you know I kind I
I like it building innovations like that
Well you know what's interesting is the
postcare denials are particularly
stinging I think because as one of our
guests over the last couple of years
coined the term we've created people who
are functionally uninsured They may have
an ID card in their wallet but
deductibles and personal responsibility
amounts have gotten so high and
convoluted that they're out of pocket
for a bunch of money anyway And so
you're taking a population that can
least afford to have these claims denied
because they don't have avenues they
don't have huge savings maybe they don't
have credit card availability or or
whatever and they're getting saddled
with this debt and you know that the the
initial study back years ago um from I
think Stephie Woolhandler when she was
at at Harvard about medical bankruptcy
was kind of questioned but there have
been a couple of new studies about the
number of bankruptcies that are that are
caused by medical debt and if you can
overturn some of this stuff it'll make a
huge difference in people's lives and
I'm interested to hear that you're doing
it as a passion project Mhm Yeah No
thanks I mean it's it's a passion
project that's actually turning into a
startup Like we've been approached by a
bunch of venture investors People kind
of realize there's like a twofold thing
that you can make and and we really all
our innovations are like impact
innovation So even Kerry itself it's not
like a traditional kind of like venture
funded um uh caregiving company Uh we're
all backed by impact innovators So Carey
itself has funding from the American
Heart Association AP as well as several
other smaller impact investors And I
think same thing with counterforce
health We're being approached by impact
investors like that who want to build
something sustainable but aren't really
sitting there trying to profit maximize
and are just like okay as long as it can
survive on its own So you know kind of
like the model is free to people
indefinitely like we spend upfront cost
building it the ongoing cost is not very
high Um and then really um clinics as
they see value um and really from a
clinical perspective it's revenue cycle
management right that a lot of the
denials especially postcare denials will
end up going into collections something
like 10 to 15% of those will just not be
paid um and then that's a problem for
the clinic that they're going to lose
you know if you kind of like do the math
on these couple of providers
experiencing 50 a week you know just
even if averaging is 200 bucks over the
course of a month and seeing 200 300
denials that's going to be you know 40
plus thousand and if 15% of those go to
collections that's a disaster right
that's a multi000 problem per month so
over time from a sustainability pathway
it's going to be okay will places like
that say hey it's worth 5% of my you
know kind of like uh how much revenue
I'm capturing back um to spend on a
product like this so you know I'd say
early conversations there but like no
real pressure to monetize but I think
investors really see the potential and I
think that passion project can turn into
something huge because I do believe from
a patient side if you charge charge It's
tough you know because now all of a
sudden you have people who are already
hesitating or don't want to fight it and
then you say "Hey five bucks to use
this." People are going like "Nah you
know even if it's on a success base I
just feel like charging one isn't the
right thing to do." And I'll say from
the inside not to market against myself
but the cost is not very high The cost
per generation is fairly low It's a
fixed-cost business that requires a lot
of software development upfront and it
requires constant training and
retraining of models but the variable
cost of the business is absurdly low So
you want to just go for maximum usage
and maximum scale And I think that's
also how you can make maximum impact So
yeah Well and I think you're right I
think you know it's it's it's a good
deed to do it on a public basis but the
sustainability is really going to be at
the doctor's office level and at the
clinic level I I cannot tell you you
know how often I hear you hear it too Um
the system is broken No the system's not
broken The system is working perfectly
It was just never designed to work for
you Yeah And and so if if if revenue
cycle management is one thing but
certainly the the um 30% that they
reclaim on claims that go into
collection would more than pay for
somebody to do this if they had a system
to do it And I I I love the idea of okay
you're using AI Here's AI back at you
Yep agreed And and I didn't even get to
the most fun part The other AI and I'll
send you a video of this if you want to
include in the um YouTube is we even
fully built a voice AI and even a video
avatar AI that's in beta right now but
some people are using because just
sending the letter you know faxing that
or mailing that isn't where the battle
stops Everybody knows you got to get on
the phone with these insurance companies
Wastes a ton of time on calls right You
see all these patient advocates doing
this on behalf of people right And you
know so we were like you can even AI
that So we built Maxwell which is a
voice AI assistant that actually the
goal is upload all this stuff generate
the letter and then have sick Maxwell on
the insurance company and he'll call the
insur on your behalf and deal with the
process for you of just like wasting
time um with the claims and billing
people Um and I think that is
interesting because they've deployed AI
bots So you know whenever you call
insurers like and we do this all the
time just as like a passion project
where we have people using our thing and
if it's like a massive claim we're like
okay let let us help you manually just
kind of for learning and for fun and you
know you call one of these insurers on
behalf of someone and you spend minutes
and minutes going through for AI bot
conversation then you get the rep on the
line you know the rep is just wasting
your time asking the same questions This
is another perfect use case of AI
because the insurers have weaponized
voice AI on you and you can weaponize it
back and say "Okay my AI Maxwell is
going to call and then one click the
whole thing." The benefit there is if
you're a cancer patient you're somebody
living with dementia you're somebody who
really doesn't have the resources or the
ability to handle all the stress to
manually fight this back you can just
have kind of the AI do it for you And I
think that that's going to be a big
thing of AI agents I know a lot of
people have been talking about this but
I think in these kind of fields from a
consumer standpoint not enough people
have developed AI agents and I think
that's really the opportunity of like
have the AI do as much of the grunt work
and the dirty work for you Um and I
think at that point it makes it more of
a fair fight What a fascinating journey
you're on I I do hope as you grow out
you'll come back and we'll talk some
more about about all this and we will we
will do another um separate episode
about care yaya and and what it does
because people who are caregivers are
the
unrecognized heroes in health care and
it it it is a huge burden and sometimes
can become as debilitating for the
caregiver as it can for the people who
are receiving care And so I more than
happy to have you back to talk about
that Neil Shaw chairman and co-founder
of Counterforce Health Neil thanks so
much for a fascinating conversation
Thanks for having me David Really
appreciate it
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CareYaya is not a licensed home care agency, as defined in Gen. Stat. 131E-136(2) and does not make guarantees concerning the training, supervision or competence of the personnel referred hereunder. We refer private, high-quality caregivers to people with disabilities and older adults.