Intel on insurance company denials | KTVU
Neal Shah, chair of Counterforce Health, gives insight on rejected insurance claims, and how patients can appeal their claims.
Transcript
a recent New York
Times investigation found $260
billion in legitimate medical
claims are denied every year. It
also says United Health Care
denied 1 in 3 in-network claims,
and that Cigna used AI to reject
over 30,000 claims in just two
months. Meanwhile, over half of
denials were overturned when the
consumer appealed. Let's get
some more insight by turning to
Neil Shaw, chairman of
Counterforce Health. It's a site
that helps patients appeal
denied claims through the use of
AI. Good morning doctor.
>> Good morning. Thank you so
much for having me.
>> It's an important topic here.
A new analysis of some 4 billion
claims found that, among other
things, prescription drug
denials by private insurers in
the U.S. Jumped 25% from 2016 to
2023. Tell us first why it's so
rare that we do get an inside
look at a very complex system of
health care claims and denials.
>> Yeah, I think what's
happened, and I think what a lot
of patients and even physicians
across America don't realize is
that in the last 3 or 4 years,
the large health insurance
companies have weaponized AI to
programmatically deny claims at
scale. So they're not even
having doctors really spend
hours or minutes reviewing these
letters. Some news stories have
come out that in 1.2 seconds, an
algorithm will just make a
decision to deny you. And then
what's a shame is that patients
and clinics across America have
to spend five ten hours writing
detailed letters to fight back.
But yeah, there's been an
escalation in denials of claims.
I think in many key medications,
1 in 4, 1 in 3 claims that are
denied. The statistics are, I
think 60 million Americans have
had a claim denied in the last
year, 1 in 5 people on health
insurance. So I think people are
realizing health insurance isn't
really healthcare these days.
It's a tragedy.
>> Experts have studied denials,
say that the skyrocketing cost
of popular new weight loss drugs
and greater automation are
likely the two big factors
leading to this change. Do you
agree?
>> Yes, well, I agree, I'd say,
frankly, automation is the
biggest. So I actually I
recently just published a book
about it you know Insured to
Death. And it's now become
unexpectedly a number one
bestseller in health policy. And
you know, you know, people
should take the time to read the
book. But really it's
automation. It's AI. You know,
they're using AI to deny claims
rapidly because it takes you
hours and hours to write an
appeal and fight back. And then
these clinics don't have the
time. They don't have the staff,
hospitals don't have the time,
and individual patients don't
have the time or even the access
to knowledge. So this is
something where we passionately
believe that AI needs to be
built for the other side. You
know, it's an arms race by AI,
and patients and clinics don't
have a chance without using AI
themselves. So that's been our
mission, and we've built a lot
of cool AI tools to help people
fight back.
>> This is almost like what
happened when I popped up in the
classroom, right? Students got
Ahold of it, ran wild. Teachers
were like, wait a minute. We
need to know about this, too. So
you're saying that AI has been
weaponized by the health care
industry, but you yourself say
your company is using AI to help
the consumer?
>> Yes. Yeah. So we actually
just as a passion project, I
run, you know, which is a large
eldercare platform around the
country. We built AI tools that
we're offering to patients and
clinics completely for free,
because we are so frustrated
with this problem that people
are experiencing. So people can
come to the site Counterforce
Health org and just use free AI
tools to fight back. You know,
it doesn't. It's not rocket
science to build AI to help you
generate a well crafted appeals
letters study claims databases,
you know, write detailed
citations for medical necessity.
But this is something that an
individual person might take 5
or 10 hours to do. A doctor
doesn't have the time. A nurse
doesn't have the time. So this
is a perfect use case for AI
where it's like repetitive
knowledge based, you know,
pulling information, parsing
through coverage policy
documents and then creating
something on the back end that
then you can submit to your
insurer.
>> So for the person who says,
look, I'm sick, I don't have
time to fight this denial. I'm
just going to pay it and move
on. What do you say to that
person?
>> No, no, no. Do not pay the
bill. That's my number one
advice to everyone. You have a
lot of rights. I wrote
extensively in my book about it,
so people should check it out.
Like you have rights to appeal
to the insurance company. You
have rights. If multiple appeals
fail, the state insurance
regulators want to help you. So
there's what's called an
external review. You have so
many rights. And if you simply
bother to fight, I'll leave
people with this. Of 99% of
denials last year were not
appealed because people didn't
know their rights. Of the 1% of
people that appealed, over half
of them were overturned. And
that's just a one simple appeal.
You do multiple appeals, your
odds go up. So people have a lot
of rights. They just don't know
their rights. So I think at a
minimum, this is a great public
service announcement. Do not pay
the first bill. If you get
denied something, you have five
different opportunities to get
the care you need.