AI Steps In to Fight Health Insurance Denials

Health insurance denials in the United States have risen lately, partly due to automated algorithms powered by AI. Now, new AI tools are pushing back by creating automatic appeals to help patients overturn these denials.

The Problem's Size

The numbers show a concerning view of healthcare now. Big insurers like UnitedHealth, Humana, and Cigna face lawsuits claiming they used algorithms to deny important care. One lawsuit says that Cigna denied over 300,000 claims in just two months—averaging about 1.2 seconds per claim reviewed by a doctor.

KFF data shows that 20% of all claims across Affordable Care Act marketplace plans were denied in 2023, affecting over 20 million people. For Medicare Advantage plans covering over 30 million people, audits found insurers wrongly deny or delay millions of requests for care each year.

Though around 40-56% of appeals succeed, less than 1% of denied claims are ever challenged. A 2023 KFF survey found that 39% of consumers struggling with medical bills said denied claims added to their money problems.

The Personal Impact

Dr. David Casarett, a medicine professor at Duke and palliative care section chief at Duke Health, has seen the impact directly. As an intensive care doctor at the University of Vermont for 20 years, she's seen denials affect her patients, like premature babies who were denied oxygen equipment.

It's gotten bad, she said. I can't believe people have to do this just to get healthcare covered—things that are basic needs.

The appeal process takes lots of time and knowledge that many patients don't have. Writing a good appeal letter can take eight hours of work, looking through billing codes, medical journals, and citations—like a full-time job on top of being sick.

AI Solutions Arrive

Several startups have created AI tools to help patients fight back:

Counterforce Health, started by Neal Shah in Research Triangle Park, North Carolina, offers a free platform that makes special appeal letters fast. The nonprofit gets money from grants from the National Institute on Aging and the University of Pennsylvania Artificial Intelligence Research.

Users upload their denial letter, medical records, and doctor's notes. The AI system then searches databases of many successful appeal strategies and current medical journals to create a research-backed appeal. One rheumatology clinic using the platform reported a 73% success rate after doing hundreds of denials.

Claimable, which started in October 2024, charges a flat fee of $39.95 plus shipping for each appeal. Co-founder Zach Veigulis calls it TurboTax for appeals. The platform focuses on conditions like rheumatic diseases, autoimmune conditions, GLP-1 drugs, and asthma-related denials, and plans to grow into oncology. Their appeal letters for rheumatic conditions have gotten an 82% success rate.

Fight Health Insurance offers a similar free service, guiding patients through their choices and making appeal letters, but the company hasn't shared detailed performance numbers.

Real Success Stories

Tammy Capper was diagnosed with kidney cancer in early 2025. After having microwave ablation to treat her cancerous tumor in February, Blue Cross Blue Shield denied her coverage, calling the process experimental and leaving her with a bill of almost $40,000.

After seeing a report about Counterforce Health on NBC Nightly News, the Cappers used the service to appeal. The denial was overturned, and Tammy is now in remission, spending more time with her grandchildren without the huge money stress.

Joani Reisen, a 60-year-old with ADHD, went almost five months without her Concerta medication after her insurance company denied prior approval, blaming clerical errors. After two failed appeals and many phone calls, she used Counterforce Health to submit a third appeal. Her denial was overturned in four days.

Stephanie Nixdorf faced nine months of denials from Premera Blue Cross for infliximab, a drug to treat bad arthritis from her cancer immunotherapy treatments. Using Claimable's AI platform, she sent a 23-page appeal letter to leaders at Premera and state officials. Two days later, the drug was approved—but the delay had already caused lasting joint damage.

How It Works

These AI platforms don't just make simple templates. They look at the insurer's reason, use clinical research, legal cases where insurers have lost, and data from successful appeals in similar situations. The aim is to create special, evidence-based appeals that are hard for insurers to ignore.

The systems access medical journals, insurance review data, and databases of past appeals to build cases. What would take an expert around 30 hours to do, these platforms can cut down to a 25-35 minute questionnaire for patients.

Privacy and Security

Consumer advocates say to be careful when uploading medical information. Once healthcare documents are shared with these services, they're not protected by HIPAA, which only applies to healthcare providers, insurers, and their direct partners.

Professor Blase Ur of the University of Chicago, who knows AI and computer ethics, says: Would you be okay posting this on the Internet? If not, don't give it to the AI language model.

But the companies have added safety measures. Counterforce offers a HIPAA-safe version where all data is removed from the user's machine before being sent to servers. Claimable says it doesn't sell consumer data and uses HIPAA-level security with safety measures. Fight Health Insurance lets users delete their data once appeals are done.

The Big Picture

While these AI tools give help now, health experts say that lasting change needs reform to control high prices and make sure of coverage. Federal and state lawmakers have started looking at automated denials more closely.

A US Senate report in October found that UnitedHealthcare, CVS, and Humana—the three biggest Medicare Advantage providers covering almost 60% of all Medicare Advantage patients—reject prior authorization claims at high rates using tech. Appealing these denials costs over $7.2 billion each year in costs for providers.

The Centers for Medicare and Medicaid Services recently said new rules will control prior authorization for Medicare Advantage plans, and several states, like Vermont, have passed laws to reduce the strain of prior authorizations.

Some worry that AI versus AI could become a costly fight. Jonathan Ernest, an economics professor at Case Western Reserve University and former insurance analyst, warns: The worry is that using these tools will cause greater costs, as each side competes.

Getting Help

For those wanting to appeal denials without AI, there are resources:

• The Public Interest Research Group offers a guide with steps to access medical records, papers, and sample appeal letters

• ProPublica's Claim File Helper tool helps make letters asking for papers insurers used when denying coverage

• Patient advocates say to first call your insurer to see if issues can be fixed without the appeals process

As Caitlin Donovan, senior director of the Patient Advocate Foundation, says: I think anything that helps patients get the care they need is good. Even with AI, though, I have to tell patients to always check their source and have someone check anything before giving it to an insurance company. Tech is a tool, not a solution.

Right now, these AI platforms are a way for patients to even the score in what Shah calls an unfair fight: Right now, insurers are using AI to deny claims fast, while patients and doctors spend hours fighting back. That's not fair. Our goal is to change that and make appeals easy.