When Insurance Companies Say “No” – Non-Profit Helps Patients Fight Claim Denials
Selecting a health insurance plan has become an annual event for millions of Americans. Whether they receive insurance through an employer, the ACA Marketplace, or Medicare/Medicare Advantage, they set to the task of weighing plan options with varying premiums, deductibles, out-of-pocket expenses, and doctor networks. However, one metric for comparing plans is virtually hidden from view: claim denial rates.
Neal Shah
“Selecting a health insurance plan is one of the most important financial decisions people make every year and it represents a large financial outlay,” said Neal Shah, cofounder and chairman of Counterforce Health. “While it’s relatively easy to compare monthly payments and deductibles, plan enrollees have no way to determine the likelihood that their claims might be denied, essentially leaving them without the coverage they have paid for.”
Shah said he discovered the enormity of insurance claim denials several years ago as his wife battled aggressive breast cancer (today she is cancer-free). As he wrote in a Los Angeles Times essay:
“We had dutifully chosen our plan during open enrollment, comparing all the metrics the system told us mattered. None of it prepared us for the cascade of denials we’d face when we actually needed care. Necessary medications labeled ‘not medically necessary.’ Treatments our plan ‘covered’ suddenly requiring endless appeals and out-of-pocket costs. All that careful open enrollment comparison? Meaningless when coverage really mattered.”
What at the time seemed like “bad luck” for Shah and his wife eventually became a catalyst for the creation of Counterforce Health, a non-profit organization dedicated to providing Americans with the tools, resources, and confidence to push back against the health insurance claim denials that aren’t just isolated incidents, but instead reality for millions of people. All of Counterforce Health’s services are completely free to use for patients.
Millions of Americans Denied Care Every Year
Insurance companies are relatively tight-lipped about their claim denial rates, making data about the scope of the problem difficult to uncover. However, health policy research organization KFF found that HealthCare.gov insurers (plans available through the federal marketplace) denied 19% of claims submitted for in-network services and 37% of claims for out-of-network services in 2023. The Commonwealth Fund also has studied the issue of coverage denials, finding in a 2023 survey of insured, working age adults that:
- Forty-five percent received a medical bill or were charged a copayment in the past year for a service they thought should have been free or covered by their insurance.
- Seventeen percent were denied coverage for care that was recommended by their doctor.
- Nearly six in ten who experienced a coverage denial said their care was delayed as a result.
“An estimated 50 million Americans are being denied care every year,” Shah said. “Denials are especially high among those with chronic conditions who have multiple instances of health care use and thus may receive multiple denials. Denial rates are also high for certain medications including biologics and those with step therapy requirements.”
According to the Commonwealth Fund survey, of those who were denied coverage, more than half said neither they nor their doctor challenged the denial.
“Of the 850 million claims that are denied every year, less than one percent are ever appealed,” Shah said. “However, when denials are appealed, up to 75% of them get approved. That’s why my advice is to appeal and keep on appealing. Don’t look at the denial as a statement of fact but rather as a starting point for negotiation.”
Counterforce Health Helps Patients Fight Back
Insurance claim denials aren’t often appealed because the process can be complicated and daunting. Denial letters (in the form of Explanation of Benefits or EOB statements), which typically come after a procedure or treatment has already occurred, contain confusing jargon difficult for most to decipher. Filing an appeal requires a fine-print understanding of the patient’s insurance policy, curation of the patient’s medical records, and citation of relevant peer-reviewed medical studies – all of which must be included in a “letter of medical necessity” to the insurance company. Each stage of the appeals process comes with tight deadlines that can be intimidating to just about anyone, especially someone already stressed physically and emotionally by a chronic or life-altering illness. Most people, said Shah, find the process impossible to navigate on their own, even if they don’t agree with the denial.
This is where Counterforce Health comes in, with its free service for patients. The non-profit uses artificial intelligence (AI) to help patients write appeals in a mere fraction of the time it would take to do so otherwise – under two minutes – and with no need to understand legal or medical jargon.
The online appeal process is simple and requires just a few clicks. Patients, their caregivers, or their health care providers start by uploading the denial letter, insurance plan details, and other relevant documents to Counterforce Health’s secure and siloed site. The HIPAA-compliant AI system triages the information, reviewing relevant medical literature and clinical guidelines, insurance policy language, and appeal regulations to build a strong, data-backed argument. It then drafts a complete, editable appeal letter, ready to send to the insurance company. Each letter is customized, citing specific plan terms and legal standards that demand coverage.
While this “DIY” approach works for many of the patients Counterforce Health helps, the organization also offers the option of working one-on-one with a case manager who can help tailor the appeal further by reviewing and editing the appeal letter, providing guidance on supporting documents, and helping to follow up if an appeal is denied. This follow up help extends to external reviews with state insurance commissioners, outreach to state legislators, and, in some cases, taking patient stories to the media in an effort to reverse a denial.
“Thanks to funding from the National Institutes of Health and the University of Pennsylvania, Counterforce Health offers these services completely free of charge to patients and their caregivers,” Shah said. “We keep working as long as the patient wants to keep appealing.”
Assistance for Rural Patients and Small Clinics
Shah noted that where a person lives can impact the likelihood that a medical claim will be denied, especially for patients living in rural areas with fewer direct care resources and alternate providers. Lower income patients are also more likely to have a claim denied, said Shah, prompting some without out-of-pocket reserves to forgo care completely rather than being saddled with a bill they cannot pay.
To help patients in rural communities – many of whom lack reliable broadband internet access – Counterforce Health initiated a program called Appeals on Wheels. They outfit a truck with a laptop computer, satellite internet, document scanner, printer, and fax machine and travel to churches, community centers, and other locations to bring the service directly to patients in need. Though the service is only available in North Carolina currently, Shah and his team are looking to operationalize it nationwide in the future.
Another way Counterforce Health assists underserved communities is through its Small Clinic Grants program, which provides funding to clinics that want to advocate for their patients but lack the resources to fight back. The funds help clinics adopt the Counterforce Health AI technology, train staff, and dedicate time to appeals, so every patient gets a fair shot at the care they need.
“We help train clinic staff to recognize which claims are likely to be denied, how to track appeal status, and ways to improve the quality of claims before they are submitted to reduce the chance of denial,” Shah said. “One clinic with our grant was able to reduce the time they spent on appeals by 80 percent.”
“While we are dedicated to providing tools that help patients, their caregivers, and their providers appeal unfair claim denials, we know that in some instances, appeals aren’t successful,” concluded Shah. “That is why we also partner with charitable foundations like the HealthWell Foundation, so we can connect patients with other forms of assistance.”
