April 8, 2025 • 28 mins
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.
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🔑 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.
🎥 Watch the Maxwell demo: https://drive.google.com/file/d/1qckxAYx10cMvA_rL_vfSHxCktF19a9Qa/view
⏱️ In This Episode
00:00 Introduction: The Problem with Denied Claims
00:59 Meet Neal Shah: A Journey from Finance to Healthcare
03:22 The Birth of Counterforce Health
06:44 Understanding the Health Insurance Crisis
11:58 Counterforce Health: How It Works
14:42 The Role of AI in Fighting Denied Claims
22:42 Future Prospects and Final Thoughts
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
450 million claims are denied each year, but fewer
than 2% are ever appealed.
And though the majority ofthose appeal denials are
overturned, only 2% are everappealed.
What's up with that and whatcan be done to even up the odds?
We'll find out on this episodeof Shift Shapers.
Speaker 2 (00:21):
Change either energizes or paralyzes.
The choice is yours.
This is the Shift Shaperspodcast, bringing the employee
benefits industry interviewswith individuals and companies
who are shaping the industryshifts.
And now here's your host, davidSaltzman.
Speaker 1 (00:42):
To help us answer that question, we've invited
Neil Shaw, chairman andco-founder of a new company
that's looking to solve thatproblem or help consumers solve
that problem called CounterforceHealth.
Welcome, Neil.
Thanks for having me.
David, it's our pleasure.
We always like to start outtalking about what your journey
is.
How do you get to be doing whatyou're doing?
(01:03):
Because almost nobody's got astraight line, Like nobody woke
up one morning in their crib andsaid I want to be in the
insurance business.
How'd you get here?
Speaker 3 (01:11):
Yeah, sure, so I actually have a completely
squiggly line to get here.
Most recently, I have actuallybeen running one of the largest
and fastest growing elder careplatforms in America called
Karyaya Health Technologies.
We're caring for thousands ofolder adults across the country,
many of whom are living withdementia.
And then, to give you kind oflike the full backstory, you
(01:33):
know most of my career.
Up until my mid-30s I was inthe finance business and I was a
hedge fund manager.
I actually experienced atremendous care needs within my
own family, starting in my early30s of taking care of my
grandfather through dementia,kidney failure, cancer and
serious illness and thenend-of-life care where I really
(01:53):
coordinated a lot of the care.
But really my mom left hercareer to be his full-time
caregiver and at that point itreally opened my eyes to how
broken kind of our healthcareand home care industry is in the
country.
And then I became kind ofobsessed with the care economy
broadly speaking and the patientexperience and the family
caregiver experience.
And at that time I was stilllike very focused on running my
(02:13):
fund.
I worked really hard all my 20sand 30s and I'd become a
partner at a multi-billiondollar fund and then I'd been
fortunate enough to have one ofthose investors back me and I
was running my own $250 millionfund, so I wasn't prepared to
kind of like leave to do this.
But then, at the peak of myfund in my mid 30s, my wife
became severely ill and wentthrough years of a cancer battle
, and at that point I kepttaking several sabbaticals from
(02:37):
running my fund to be her fulltime caregiver.
And ultimately I actually hadto make the difficult decision
to wind down my fund to become afull-time caregiver for a
couple of years, because Ithought it would make a huge
impact on her ultimate outcomeand recovery, which you know,
knock on wood, it did.
You know she's now been inremission for a few years and I
think that's in no small part tojust managing her care very
(02:59):
closely.
And at that point, you know, Ileft behind my finance career
and decided to start a carecompany.
I thought that the home caremarket in the country was really
broken.
I wanted to make innovations toimprove it and so I started
Keriaya, which has now becomeone of the fastest growing
startups, helping care forpeople in their homes and
connecting them with greatcaregivers who are all college
(03:20):
students going to the healthcare field.
We did that.
And then that whole journey andreally seeing what my experience
was and my wife's experiencewas as a patient with the system
and how many times we fought,denied health insurance claims
for legitimate treatments andprocedures and medications that
were needed during a difficultand dark journey of cancer, and
(03:42):
then in three years of runningKaryaya and seeing how many
people at varying illnesses youknow, starting with dementia,
terminal cancer, you know kindof many other chronic conditions
are facing this kind of likeinsurance battle them and their
family caregivers.
I think that really inspired mein recent months to start
(04:02):
Counterforce Health.
You know, I thought that therewas a huge gap in the market,
nothing built to improve thepatient experience as well as
geared towards small clinics,and I thought that there was a
huge opportunity.
So that's been kind of likeit's been really a personal
journey and then also recently aprofessional journey of seeing
just where there are gaps in themarket.
Speaker 1 (04:20):
It's unsurprising how many entrepreneurs get into
trying to solve a problembecause they've experienced it
themselves.
With all due respect to SimonSinek, 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?
Why isn't there a way to solvethis problem?
Why isn't there a way to dothis easier and just for our
(04:41):
listeners and viewers on YouTube?
We will do a second interviewwith Neil.
All about CareYaya, but that'sC-A-R-E-Y-A-Y-Aorg correct.
Speaker 3 (04:52):
Yes, that's right.
Speaker 1 (04:54):
If you want to go get a jump on our podcast.
If not, we'll be talking toNeil again soon about that.
But today we're talking allabout counterforce health, and
when we first talked about this,Neil, one of the things you did
was you used an analogy of arestaurant and meals and whatnot
.
Can you share that with theaudience?
Speaker 3 (05:12):
Yeah, I wrote an article about it recently that I
kind of put out on LinkedInPulse.
Can you imagine if somebodysells you a subscription that
you can eat at a restaurant orother restaurants twice a week
for a year and pay me a couplethousand bucks a year?
And you can eat at a restaurantor other restaurants twice a
week for a year and, you know,pay me a couple thousand bucks a
year and you can enjoy thisprivilege?
And then you show up andthey're like oh, actually, no,
(05:32):
you can't eat today.
Like do you actually need food?
Oh, we're only serving this andthis.
You know, and I think that'skind of like that's been the
real, you know, kind of likepeople really needed to still
what health insurance is, tokind of um, you know other
analogies of things they mightuse in life, like subscription
services for food, subscriptionservices for meal delivery,
where, if you pay up front, andthen when you go to capitalize
(05:54):
on, like, ok, I need this andyou don't get it, especially
during moments of extreme duressthat people are under, whether
it's they're managing care for amother or father through
dementia or they're managingcare for a spouse through cancer
(06:15):
.
You know these are notsituations where you want to
deal with financial stress andexistential stress of like am I
going to be able to get this?
You know that's why you'repaying.
You know during good timesyou're paying, so during bad
times you can kind of have thecoverage and I think then people
are really shocked that theycan't get it when they need it.
Speaker 1 (06:29):
Well, because you know, as we've said frequently
on the program, there's onlythree things you can do with
risk you can keep it, you cantake it, you can share it,
rather, or you can give it awayand you know, to a certain
extent you expect that you'vegiven it away and you shouldn't
have to deal with all thisnonsense on the back end.
So we talked a little bit aboutthe number of claims that are
denied 450 million claims, thatclaims like, of all types.
Speaker 3 (06:54):
Of all types.
Yeah, I mean I think basically,the statistic from the American
Hospital Association is that onein five American adults with
health insurance have had adenied claim within the last
year Right, shocking, I think.
The other interesting statisticis that about 10 to 15 years ago
, the average denial rates atmany large insurers were less
(07:16):
than 2% and now they've turnedinto anywhere from 15 to 25%,
and you know that was kind ofKaiser Family Foundation had put
out a detailed research reporton it.
So it's that a lot of peopleare experiencing this issue and
the issue has gotten notablyworse in the last five to 10
years.
The third interesting statisticis that when they surveyed
(07:37):
physicians as recently as 2022,something like 23% of physicians
said claims denials are a majorproblem for me, and then from
2022 to 2024, when the surveywas done, now 74% of physicians
are saying claims denials hasbecome a big problem.
So this has been growing kindof throughout the 2010s and the
(08:01):
early 2020s, which I have atheory on that, you know,
related to kind of Obamacare anda variety of other things, but
it has skyrocketed in the lastthree years and I believe that
is fully on the part of AI andweaponization of AI by health
insurance companies andasymmetric warfare.
You know where?
Speaker 1 (08:18):
patients and providers have a conversation
that's going on withUnitedHealthcare and you know
they're kind of in the front ofthat, but there are others as
well, so I'm interested.
You mentioned that you have atheory about why this has
skyrocketed.
Would you share that with us?
Speaker 3 (08:29):
Yeah, sure, I mean I think the theory is multifold.
One I think Obamacare, while itmay have been a
well-intentioned policy to getmore people covered, in reality
it became a big kind of boost toprivate health insurance and
really for-profit healthinsurance, right Like getting a
lot more people on insuranceplans.
Combined with a relatively laxapproach to regulation and
(08:53):
specifically antitrust andmergers, created this kind of
like monster.
And if you kind of think about,like you know, many, many times
, you may think who reallybenefited 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 thepolicy 15 years, it's almost
like UnitedHealthcare could havewritten that policy, because
(09:13):
how did they benefit?
Twofold One they got a lot ofcustomers.
They got kind of risk coveredwhere government paid them out
if there was too much risk.
You force people to buy privatehealth insurance for profit and
then you allowed a series ofmergers with no check or
regulation, so these guys couldnot only gobble up other
insurers but kind of go andvertically integrated and buy up
(09:34):
PBMs and other parts of thehealthcare value chain and buy,
even buy up physician practices.
So I think that that Obamacarewas kind of like the start of it
.
In my opinion, if, like, you cansee insurance claim denial
rates and how the insuranceindustry is operating because
it's been around since whatever60 plus years before, but
starting in the early 2010s, thewhich is just happened to be
coincidental with when Obamacarepasses the behavior starts
(09:57):
going a little bit off.
You know off skelter rightwhere it's like okay, denial
rates start rising, then mergersstart happening like crazy, and
then now you have it where,like you know, between a handful
of you know four or five guysyou know United, humana, cigna,
whatever they effectivelycontrol the market.
You know you don't have a lotof choice and, depending on what
employer you are or what stateyou're in, sometimes you're
(10:17):
limited to a handful of choices.
So market share concentrationhas gotten absurd.
Then many of them havevertically integrated in other
parts of the healthcare valuechain.
So you know they're kind oflike flexing power on even what
physicians are able to do, whatpharmacies are able to do, et
cetera.
So I think that it has been likereally a complete regulatory
and market failure that'sresulted in this kind of like,
(10:38):
almost like I wouldn't even callthis capitalism, like I'm a
hardcore capitalist, but likecapitalist in the sense of free
markets and competition.
I would consider this almostlike crony capitalism, where a
handful of mega companies aretaking part of the regulatory
infrastructure to then flexmarket power and then keep
(10:58):
competition out and then alsohave no responsibility to
consumer, who is the ultimateend buyer, and then using a
government as a way to forcepeople into their product.
So, yeah, I mean, I think it'sabsolutely disaster.
So I mean I think and it'sbipartisan, right, I mean I
think it's not Democrat orRepublican.
I think there have been tons ofadministrations, obviously not
just at the presidential level,but even, you know, people in
(11:21):
Senate and Congress, you knowkind of like thinking about what
to do about insurance.
But yeah, I think it's been abipartisan complete disaster and
I think that's going to have tochange.
Speaker 1 (11:31):
Interesting.
I wish I could disagree withyou, but I unfortunately can't.
And I've been around this for40 plus years and I've done I
mean, I've run TPAs, I've paidclaims.
I see the correlation andcausation, both.
And it's frightening because ifyou take this out on a line,
where are we going to end up andis something just going to
(11:53):
implode as we go along?
But let's get back tocounterforce.
So you saw this problem upclose and personal, especially
with your wife's struggle, andyou decided, okay, there's got
to be a better way to get peopleto easily appeal claims.
What does Counterforce do?
Is it aimed at the patient orthe physician, or both?
Give us a little background,and I know you're using AI to
(12:16):
craft the solution, so tell us alittle bit about that.
Speaker 3 (12:19):
Yeah, yeah, sure.
So I think you started theinterview with kind of like the
statistic that I thought was,like you know, the most
capturing.
It's like less than a fewpercent of people appeal claims,
right?
So there's so many deniedclaims across America, you know,
in the hundreds of millions,something like 49 million
individuals have had a claimdenied within the last year.
And depending on which stat youread, it's like some people say
(12:39):
2%, some people say 1% thatactually bother appealing, so
vast majority of people are notappealing.
Some people say 1%, thatactually bother appealing, so
vast majority of people are notappealing.
If you kind of get into thereasons why, it's really 70% of
people don't fully know theirappeal rights.
So they don't know they can doit or how to do it, things like
that.
40% of people say they're toointimidated or lack the time or
(13:00):
the resources or expertise to doit.
So you know, and of coursethere's an overlap, like 70 plus
40 is more than 100, right.
So some don't know how to do itand some of those are also I
don't know who to get for help.
So we kind of thought there'stwo things you could do here.
You know you could do masspublic awareness combined with
tools to make it as easy aspossible or one click as
(13:20):
possible.
So what is the current appealprocess like for most people,
let's say the 70% of people arelike I don't know how to do it.
I'm too scared For the peoplethat do know how to do it are
like okay, I can try.
You know I feel like you needto have a doctor in your family
to sit down and do hours andhours of research.
You know to fix.
You know billing codes are.
24% of denied claims are becauseincorrect billing code.
(13:40):
Another 40% are due to medicalnecessity.
So billing codes are somethingthat you could look up in
billing code databases, fixyourself right.
That's something theoreticallythe insurance company should you
know, theoretically maybe evenfix for you, but you know it's
maybe a frivolous reason to deny.
So that is something where, ifyou had a doctor in your family,
you could do it.
If you had the time and thebandwidth, you can go search
(14:01):
databases, you can use AIyourself.
But most people are intimidated.
They won't do it, especiallymost people who are like less
affluent, maybe less educated,in more rural areas.
They're going to be like Idon't know how to navigate this
stuff right.
So there's a health and a techliteracy component to that of
why people aren't appealing, andthen it happens that those are
probably the people who canleast afford to have the thing
denied.
So that's a perfect use casefor somebody doing it for them.
(14:31):
And then medical necessitythat's one where you have to
kind of go get doctors todetailed site why something is
needed, you know, pullreferences from medical journals
or other cases and say thistreatment is needed for X, y, z,
and that's another thing wheremost kind of lay people will be
like I lack the expertise to.
So over the last several monthswe built a set of AI tools
training them on a lot ofdatabases of seeing what
successful appeals have worked,which things have even gone to
(14:51):
independent review, which haveworked, even training it on
legal databases that have thingsall the way gone to court and
then learned successful appealstrategies and been able to real
timetime access journals andmedical literature databases as
well as billing code databases.
To say, for any person whocomes in, whether in a rural
(15:13):
area, urban area, uneducatedperson, minimally educated or
super well-educated you know youcould even be a doctor yourself
.
Come into Counterforce Healthand upload your policy document,
upload your denial letter,upload any relevant information,
and just one click and sitthere and in less than two
minutes, a super detailed,well-crafted, eight plus pages
(15:35):
appeal letters with detailedcitations will be done for you
at no cost, and we run itcompletely for free.
By the way, it's a socialmission, you know.
I really just wanted to offerit to individuals for free.
So you know that I think can'tbe beat.
I think a lot of individuals,even if they had a brother
that's a doctor might still havetheir brother.
(15:56):
Take, you know, six hours, 10hours, to write something like
that, and we can do it with AIin a matter of you know seconds.
It, having trained on tons andtons of databases, absorb really
good information.
And then to your point about whothe users are, believe it or
not, clinics are also using itand there, ultimately, that'll
be the path to sustainability isthat we find many clinics,
(16:16):
especially small practices.
You know we don't kind of likeinitially start and gear towards
big hospitals.
I think a lot of them aretrying to do this stuff in house
, and good for them, you knowthey need to be, but there's
many, you know.
We have a rheumatologist youknow it's two doctors running a
small practice here in a smalltown in North Carolina and they
see tons of patients and they'reaveraging something like 35 to
(16:37):
40 denials per week and theyhave one administrative person
that handles kind of scheduling,billing, payments etc.
And then whenever she has timeshe will write a few appeal
letters.
And you know I was talking toher a couple weeks ago and she
was like, yeah, typically we'llwrite maybe three, four letters,
if I can, per week.
You know it takes me a couplehours each.
It's a lot of work and she, youknow she has a full time job
(16:58):
doing other stuff.
This is an example where theystarted coming to Counterforce
Health.
Now she's writing 40 appealletters a week.
You know kind of like this andshe would say they're better
than what she was writing byherself because they're much
more detailed and, you know,kind of much better cited.
So I think that's really kindof the power of AI.
I really believe thatdemocratizing access to this.
You know it's like if theinsurers have weaponized AI,
(17:21):
it's now time to provideindividual patients and small
clinics the same weapon to fightback, because I think it's been
asymmetric warfare until now.
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And now back to ourconversation.
I know you guys are early inthe process.
Are you keeping stats withusers?
Are you asking them forfeedback on what the percentage
of claims that get denied areoverturned when they use the
system?
Speaker 3 (19:24):
Yes, yeah, yeah.
So we're keeping stats and sofar it's surprisingly good.
Now there might be an adverseselection bias, like people who
are more intending to fight cometo the thing, but on average
it's averaging over 70%, like72% as of last set, which is
like surprisingly good, I think.
Average appeal you know,average appeal win rates in the
country, depending on which statyou look at, are somewhere like
40 to 50%.
(19:45):
So there's already kind of anincentive of if you simply
bother to write a letter, evenif you don't use counterforce
health, write it yourself, dowhatever right, use chat, upt, I
don't care, just bother doingan appeal, you'll win 40 to 50%
of the time.
Then the better the appealletter is, the more you'll win.
So yeah, like it's really coolto see 70% plus win rate.
(20:05):
I mean that's, that'sunbelievable right.
And it's like billing codeerror related appeals.
I mean those are extremely,extremely easy to fix and
address and there it's just amatter of taking the time to do
it, medically necessary a littlebit harder.
In many cases it just won't bedone, but again, easy enough to
address.
And then there's sometimes backand forth.
But what we find in manysituations is that people just
(20:29):
due to inertia, intimidation.
We're just simply not botheringto do it.
And then post care denials areeven.
I mean, I think those are, youknow, terrible right, like where
people have these $100 bills,$200 bills, where insurers is
like frivolously denying andmost people like I'll just pay
it out.
You know, I was actually.
I was talking to a ladyactually that we helped through
our care platform, living with ametastatic breast cancer in her
(20:51):
mid 70s, and she's been takingthis one routine med for the
last couple of years, 50 bucks amonth, and it got denied.
And this is before she knewabout counterforce and she just
paid it.
And I was like why did you paythat?
Like, why did you bother?
And she's like, well, she'slike calculating, she's like
calculating.
She's like, yeah, the stress ofwriting a letter, the stress of
researching, you know fighting.
She's like I just don't want todeal with all that.
I'm already going throughcancer.
(21:12):
I'm thinking about how muchlonger I got.
So she just kind of said it'seasier to pay the 50 bucks.
So it's like those things in myopinion that should be a close
(21:35):
to 100.
A thing that spits out a letterin one minute, then sure that's
worth 50 bucks at a time.
Speaker 1 (21:38):
So I like building innovations like that.
Well, what's interesting is thepost-care denials are
particularly stinging, I think,because as one of our guests
over the last couple of yearscoined the term we've created
people who are functionallyuninsured.
They may have an ID card intheir wallet, but deductibles
and personal responsibilityamounts have gotten so high and
convoluted that they're out ofpocket for a bunch of money
(21:59):
anyway.
And so you're taking apopulation that can least afford
to have these claims deniedbecause they don't have avenues,
they don't have huge savings,maybe they don't have credit
card availability or whatever,and they're getting saddled with
this debt.
And you know that the initialstudy back years ago from, I
think, steffi Wohlhandler whenshe was at Harvard, about
(22:22):
medical bankruptcy was kind ofquestioned.
But there have been a couple ofnew studies about the number of
bankruptcies that are caused bymedical 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 thatyou're doing it as a passion
project.
Speaker 3 (22:39):
Yeah, no thanks.
I mean it's a passion projectthat's actually turning into a
startup Like we've beenapproached by a bunch of venture
investors.
People kind of realize there'slike a twofold thing that you
can make and we really all ourinnovations are like impact
innovation.
So even Keriaya itself it's notlike a traditional kind of like
venture funded caregivingcompany.
We're all backed by impactinnovators.
So Keriaya itself has fundingfrom the American Heart
(23:01):
Association, aarp, as well asseveral other smaller impact
investors.
And I think same thing withCounterforce Health.
We're being approached byimpact investors like that who
want to build somethingsustainable but aren't really
sitting there trying to profitmaximize and they're just like
OK, as long as it can survive onits own.
So you know, kind of like themodel is free to people
indefinitely, like we spentupfront costs building it, the
ongoing cost is not very high.
(23:21):
And then really clinics as theysee value and really from a
clinical perspective it'srevenue cycle management right
that a lot of the denials,especially post-care denials,
will end up going intocollections.
Something like 10% to 15% ofthose will just not be paid and
then that's a problem for theclinic that they're going to
lose.
You know, if you kind of likedo the math on these couple of
(23:45):
providers experiencing 50 a week, you know, just, even if
averaging is $200 over thecourse of a month and seeing 200
, 300 denials, that's going tobe $40,000 plus.
And if 15% of those go tocollections, that's a disaster.
Right, that's a multi-thousanddollar problem per month.
So over time, from asustainability pathway, it's
going to be okay.
Will places like that say, hey,it's worth 5% of my, how much
(24:06):
revenue I'm capturing back tospend on a product like this.
So I'd say early, you know,kind of like how much revenue
I'm capturing back to spend on aproduct like this.
So you know, I'd say earlyconversations there, but like no
real pressure to monetize.
But I think investors reallysee the potential and I think
that passion project can turninto something huge.
Because I do believe, from apatient side, if you charge it's
tough, you know, because nowall of a sudden you have people
who are already hesitating ordon't want to fight it and then
(24:30):
you say, hey, five bucks to usethis.
People are like, nah, even ifit's on a success base, I just
feel like charging one isn't theright thing to do and I'll say
from the inside, not to marketagainst myself.
But the cost is not very high.
The cost per generation isfairly low.
It's a fixed cost business thatrequires a lot of software
development upfront and itrequires constant training and
retraining of models, but thevariable cost of the business is
(24:53):
absurdly low.
So you want to just go formaximum usage and maximum scale,
and I think that's also how youcan make maximum impact.
Speaker 1 (25:01):
So yeah, Well, I think you're right.
I think you know it's a gooddeed to do it on a public basis,
but the sustainability isreally going to be at the
doctor's office level and at theclinic level.
I cannot tell you how often Ihear you hear it too the system
is broken.
No, the system's not broken.
The system is working perfectly.
It was just never designed towork for you.
(25:23):
Yeah, and so if revenue cyclemanagement is one thing, but
certainly the 30% that theyreclaim on claims that go into
collection would more than payfor somebody to do this if they
had a system to do it, and Ilove the idea of okay, you're
using AI, here's AI back at you.
Speaker 3 (25:43):
Yep Agreed, and I didn't even get to the most fun
part.
And I didn't even get to themost fun part.
The other AI and I'll send youa video of this if you want to
include in the YouTube is weeven fully built a voice AI and
even a video avatar AI.
That's in beta right now butsome people are using because
just sending the letter, youknow, faxing that or mailing
that isn't where the battlestops.
Everybody knows you got to geton the phone with these
(26:03):
insurance companies, waste a tonof time on calls, right?
You see all these patientadvocates doing this on behalf
of people, right, and you know?
So we were like you can even AIthat.
So we built Maxwell, which is avoice AI assistant.
That actually the goal isupload all this stuff, generate
the letter and then have sickMaxwell on the insurance company
and he'll call the insurer onyour behalf and deal with the
(26:27):
process for you of just likewasting time with the claims and
billing people.
And I think that is interestingbecause they've deployed AI
bots.
So you know, whenever you callinsurers, like and we do this
all the time just as like apassion project where we have
people using our thing, and ifit's like a massive claim, we're
like, okay, let us help youmanually, just kind of for
learning and for fun.
And you know you call one ofthese insurers on behalf of
(26:49):
someone and you spend minutesand minutes going through the AI
bot conversation.
Then you get the rep on theline.
You know the rep is justwasting your time asking the
same questions.
This is another perfect use caseof AI, because the insurers
have weaponized voice AI on youand you can weaponize it back
and say, okay, my AI Maxwell isgoing to call and then one click
the whole thing.
The benefit there is if you'rea cancer patient, you're
(27:10):
somebody living with dementia,you're somebody who really
doesn't have the resources orthe ability to handle all the
stress to manually fight thisback, you can just have kind of
the AI do it for you.
And I think that that's goingto be a big thing of AI agents.
I know a lot of people havebeen talking about this, but I
think in these kinds of fields,from a consumer standpoint, not
enough people have developed AIagents and I think that's really
the opportunity of like havethe AI do as much of the grunt
(27:32):
work and the dirty work for you.
And I think at that point itmakes it more of a fair fight.
Speaker 1 (27:37):
What a fascinating journey you're on.
I do hope, as you grow out,you'll come back and we'll talk
some more about all this, and wewill do another separate
episode about CareYaya and whatit does, because people who are
caregivers are the unrecognizedheroes in healthcare, and it is
a huge burden and sometimes canbecome as debilitating for the
(27:59):
caregiver as it can for thepeople who are receiving care,
and so I'm more than happy tohave you back to talk about that
.
Neil Shaw, chairman andco-founder of Counterforce
Health.
Neil, thanks so much for afascinating conversation.
Speaker 3 (28:11):
Thanks for having me, david, really appreciate it.
Speaker 1 (28:19):
I want to give a quick shout out to our sponsor
and our producer, hatcher Media.
Hey, if you need podcastproduction or professional
graphic design, josh Hatcher isthe expert to contact For more
information.
Visit him at hatchermedianet.
That's H-A-T-C-H-E-R media dotnet.
Speaker 2 (28:38):
This Shift Shapers podcast is copyrighted content
and may not be reproduced inwhole or in part without the
express written permission ofShift Shapers Solutions LLC.
Copyright 2024.
450 million claims are denied each year, but fewer
than 2% are ever appealed.
And though the majority ofthose appeal denials are
overturned, only 2% are everappealed.
What's up with that and whatcan be done to even up the odds?
We'll find out on this episodeof Shift Shapers.
Speaker 2 (00:21):
Change either energizes or paralyzes.
The choice is yours.
This is the Shift Shaperspodcast, bringing the employee
benefits industry interviewswith individuals and companies
who are shaping the industryshifts.
And now here's your host, davidSaltzman.
Speaker 1 (00:42):
To help us answer that question, we've invited
Neil Shaw, chairman andco-founder of a new company
that's looking to solve thatproblem or help consumers solve
that problem called CounterforceHealth.
Welcome, Neil.
Thanks for having me.
David, it's our pleasure.
We always like to start outtalking about what your journey
is.
How do you get to be doing whatyou're doing?
(01:03):
Because almost nobody's got astraight line, Like nobody woke
up one morning in their crib andsaid I want to be in the
insurance business.
How'd you get here?
Speaker 3 (01:11):
Yeah, sure, so I actually have a completely
squiggly line to get here.
Most recently, I have actuallybeen running one of the largest
and fastest growing elder careplatforms in America called
Karyaya Health Technologies.
We're caring for thousands ofolder adults across the country,
many of whom are living withdementia.
And then, to give you kind oflike the full backstory, you
(01:33):
know most of my career.
Up until my mid-30s I was inthe finance business and I was a
hedge fund manager.
I actually experienced atremendous care needs within my
own family, starting in my early30s of taking care of my
grandfather through dementia,kidney failure, cancer and
serious illness and thenend-of-life care where I really
(01:53):
coordinated a lot of the care.
But really my mom left hercareer to be his full-time
caregiver and at that point itreally opened my eyes to how
broken kind of our healthcareand home care industry is in the
country.
And then I became kind ofobsessed with the care economy
broadly speaking and the patientexperience and the family
caregiver experience.
And at that time I was stilllike very focused on running my
(02:13):
fund.
I worked really hard all my 20sand 30s and I'd become a
partner at a multi-billiondollar fund and then I'd been
fortunate enough to have one ofthose investors back me and I
was running my own $250 millionfund, so I wasn't prepared to
kind of like leave to do this.
But then, at the peak of myfund in my mid 30s, my wife
became severely ill and wentthrough years of a cancer battle
, and at that point I kepttaking several sabbaticals from
(02:37):
running my fund to be her fulltime caregiver.
And ultimately I actually hadto make the difficult decision
to wind down my fund to become afull-time caregiver for a
couple of years, because Ithought it would make a huge
impact on her ultimate outcomeand recovery, which you know,
knock on wood, it did.
You know she's now been inremission for a few years and I
think that's in no small part tojust managing her care very
(02:59):
closely.
And at that point, you know, Ileft behind my finance career
and decided to start a carecompany.
I thought that the home caremarket in the country was really
broken.
I wanted to make innovations toimprove it and so I started
Keriaya, which has now becomeone of the fastest growing
startups, helping care forpeople in their homes and
connecting them with greatcaregivers who are all college
(03:20):
students going to the healthcare field.
We did that.
And then that whole journey andreally seeing what my experience
was and my wife's experiencewas as a patient with the system
and how many times we fought,denied health insurance claims
for legitimate treatments andprocedures and medications that
were needed during a difficultand dark journey of cancer, and
(03:42):
then in three years of runningKaryaya and seeing how many
people at varying illnesses youknow, starting with dementia,
terminal cancer, you know kindof many other chronic conditions
are facing this kind of likeinsurance battle them and their
family caregivers.
I think that really inspired mein recent months to start
(04:02):
Counterforce Health.
You know, I thought that therewas a huge gap in the market,
nothing built to improve thepatient experience as well as
geared towards small clinics,and I thought that there was a
huge opportunity.
So that's been kind of likeit's been really a personal
journey and then also recently aprofessional journey of seeing
just where there are gaps in themarket.
Speaker 1 (04:20):
It's unsurprising how many entrepreneurs get into
trying to solve a problembecause they've experienced it
themselves.
With all due respect to SimonSinek, 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?
Why isn't there a way to solvethis problem?
Why isn't there a way to dothis easier and just for our
(04:41):
listeners and viewers on YouTube?
We will do a second interviewwith Neil.
All about CareYaya, but that'sC-A-R-E-Y-A-Y-Aorg correct.
Speaker 3 (04:52):
Yes, that's right.
Speaker 1 (04:54):
If you want to go get a jump on our podcast.
If not, we'll be talking toNeil again soon about that.
But today we're talking allabout counterforce health, and
when we first talked about this,Neil, one of the things you did
was you used an analogy of arestaurant and meals and whatnot
.
Can you share that with theaudience?
Speaker 3 (05:12):
Yeah, I wrote an article about it recently that I
kind of put out on LinkedInPulse.
Can you imagine if somebodysells you a subscription that
you can eat at a restaurant orother restaurants twice a week
for a year and pay me a couplethousand bucks a year?
And you can eat at a restaurantor other restaurants twice a
week for a year and, you know,pay me a couple thousand bucks a
year and you can enjoy thisprivilege?
And then you show up andthey're like oh, actually, no,
(05:32):
you can't eat today.
Like do you actually need food?
Oh, we're only serving this andthis.
You know, and I think that'skind of like that's been the
real, you know, kind of likepeople really needed to still
what health insurance is, tokind of um, you know other
analogies of things they mightuse in life, like subscription
services for food, subscriptionservices for meal delivery,
where, if you pay up front, andthen when you go to capitalize
(05:54):
on, like, ok, I need this andyou don't get it, especially
during moments of extreme duressthat people are under, whether
it's they're managing care for amother or father through
dementia or they're managingcare for a spouse through cancer
(06:15):
.
You know these are notsituations where you want to
deal with financial stress andexistential stress of like am I
going to be able to get this?
You know that's why you'repaying.
You know during good timesyou're paying, so during bad
times you can kind of have thecoverage and I think then people
are really shocked that theycan't get it when they need it.
Speaker 1 (06:29):
Well, because you know, as we've said frequently
on the program, there's onlythree things you can do with
risk you can keep it, you cantake it, you can share it,
rather, or you can give it awayand you know, to a certain
extent you expect that you'vegiven it away and you shouldn't
have to deal with all thisnonsense on the back end.
So we talked a little bit aboutthe number of claims that are
denied 450 million claims, thatclaims like, of all types.
Speaker 3 (06:54):
Of all types.
Yeah, I mean I think basically,the statistic from the American
Hospital Association is that onein five American adults with
health insurance have had adenied claim within the last
year Right, shocking, I think.
The other interesting statisticis that about 10 to 15 years ago
, the average denial rates atmany large insurers were less
(07:16):
than 2% and now they've turnedinto anywhere from 15 to 25%,
and you know that was kind ofKaiser Family Foundation had put
out a detailed research reporton it.
So it's that a lot of peopleare experiencing this issue and
the issue has gotten notablyworse in the last five to 10
years.
The third interesting statisticis that when they surveyed
(07:37):
physicians as recently as 2022,something like 23% of physicians
said claims denials are a majorproblem for me, and then from
2022 to 2024, when the surveywas done, now 74% of physicians
are saying claims denials hasbecome a big problem.
So this has been growing kindof throughout the 2010s and the
(08:01):
early 2020s, which I have atheory on that, you know,
related to kind of Obamacare anda variety of other things, but
it has skyrocketed in the lastthree years and I believe that
is fully on the part of AI andweaponization of AI by health
insurance companies andasymmetric warfare.
You know where?
Speaker 1 (08:18):
patients and providers have a conversation
that's going on withUnitedHealthcare and you know
they're kind of in the front ofthat, but there are others as
well, so I'm interested.
You mentioned that you have atheory about why this has
skyrocketed.
Would you share that with us?
Speaker 3 (08:29):
Yeah, sure, I mean I think the theory is multifold.
One I think Obamacare, while itmay have been a
well-intentioned policy to getmore people covered, in reality
it became a big kind of boost toprivate health insurance and
really for-profit healthinsurance, right Like getting a
lot more people on insuranceplans.
Combined with a relatively laxapproach to regulation and
(08:53):
specifically antitrust andmergers, created this kind of
like monster.
And if you kind of think about,like you know, many, many times
, you may think who reallybenefited 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 thepolicy 15 years, it's almost
like UnitedHealthcare could havewritten that policy, because
(09:13):
how did they benefit?
Twofold One they got a lot ofcustomers.
They got kind of risk coveredwhere government paid them out
if there was too much risk.
You force people to buy privatehealth insurance for profit and
then you allowed a series ofmergers with no check or
regulation, so these guys couldnot only gobble up other
insurers but kind of go andvertically integrated and buy up
(09:34):
PBMs and other parts of thehealthcare value chain and buy,
even buy up physician practices.
So I think that that Obamacarewas kind of like the start of it
.
In my opinion, if, like, you cansee insurance claim denial
rates and how the insuranceindustry is operating because
it's been around since whatever60 plus years before, but
starting in the early 2010s, thewhich is just happened to be
coincidental with when Obamacarepasses the behavior starts
(09:57):
going a little bit off.
You know off skelter rightwhere it's like okay, denial
rates start rising, then mergersstart happening like crazy, and
then now you have it where,like you know, between a handful
of you know four or five guysyou know United, humana, cigna,
whatever they effectivelycontrol the market.
You know you don't have a lotof choice and, depending on what
employer you are or what stateyou're in, sometimes you're
(10:17):
limited to a handful of choices.
So market share concentrationhas gotten absurd.
Then many of them havevertically integrated in other
parts of the healthcare valuechain.
So you know they're kind oflike flexing power on even what
physicians are able to do, whatpharmacies are able to do, et
cetera.
So I think that it has been likereally a complete regulatory
and market failure that'sresulted in this kind of like,
(10:38):
almost like I wouldn't even callthis capitalism, like I'm a
hardcore capitalist, but likecapitalist in the sense of free
markets and competition.
I would consider this almostlike crony capitalism, where a
handful of mega companies aretaking part of the regulatory
infrastructure to then flexmarket power and then keep
(10:58):
competition out and then alsohave no responsibility to
consumer, who is the ultimateend buyer, and then using a
government as a way to forcepeople into their product.
So, yeah, I mean, I think it'sabsolutely disaster.
So I mean I think and it'sbipartisan, right, I mean I
think it's not Democrat orRepublican.
I think there have been tons ofadministrations, obviously not
just at the presidential level,but even, you know, people in
(11:21):
Senate and Congress, you knowkind of like thinking about what
to do about insurance.
But yeah, I think it's been abipartisan complete disaster and
I think that's going to have tochange.
Speaker 1 (11:31):
Interesting.
I wish I could disagree withyou, but I unfortunately can't.
And I've been around this for40 plus years and I've done I
mean, I've run TPAs, I've paidclaims.
I see the correlation andcausation, both.
And it's frightening because ifyou take this out on a line,
where are we going to end up andis something just going to
(11:53):
implode as we go along?
But let's get back tocounterforce.
So you saw this problem upclose and personal, especially
with your wife's struggle, andyou decided, okay, there's got
to be a better way to get peopleto easily appeal claims.
What does Counterforce do?
Is it aimed at the patient orthe physician, or both?
Give us a little background,and I know you're using AI to
(12:16):
craft the solution, so tell us alittle bit about that.
Speaker 3 (12:19):
Yeah, yeah, sure.
So I think you started theinterview with kind of like the
statistic that I thought was,like you know, the most
capturing.
It's like less than a fewpercent of people appeal claims,
right?
So there's so many deniedclaims across America, you know,
in the hundreds of millions,something like 49 million
individuals have had a claimdenied within the last year.
And depending on which stat youread, it's like some people say
(12:39):
2%, some people say 1% thatactually bother appealing, so
vast majority of people are notappealing.
Some people say 1%, thatactually bother appealing, so
vast majority of people are notappealing.
If you kind of get into thereasons why, it's really 70% of
people don't fully know theirappeal rights.
So they don't know they can doit or how to do it, things like
that.
40% of people say they're toointimidated or lack the time or
(13:00):
the resources or expertise to doit.
So you know, and of coursethere's an overlap, like 70 plus
40 is more than 100, right.
So some don't know how to do itand some of those are also I
don't know who to get for help.
So we kind of thought there'stwo things you could do here.
You know you could do masspublic awareness combined with
tools to make it as easy aspossible or one click as
(13:20):
possible.
So what is the current appealprocess like for most people,
let's say the 70% of people arelike I don't know how to do it.
I'm too scared For the peoplethat do know how to do it are
like okay, I can try.
You know I feel like you needto have a doctor in your family
to sit down and do hours andhours of research.
You know to fix.
You know billing codes are.
24% of denied claims are becauseincorrect billing code.
(13:40):
Another 40% are due to medicalnecessity.
So billing codes are somethingthat you could look up in
billing code databases, fixyourself right.
That's something theoreticallythe insurance company should you
know, theoretically maybe evenfix for you, but you know it's
maybe a frivolous reason to deny.
So that is something where, ifyou had a doctor in your family,
you could do it.
If you had the time and thebandwidth, you can go search
(14:01):
databases, you can use AIyourself.
But most people are intimidated.
They won't do it, especiallymost people who are like less
affluent, maybe less educated,in more rural areas.
They're going to be like Idon't know how to navigate this
stuff right.
So there's a health and a techliteracy component to that of
why people aren't appealing, andthen it happens that those are
probably the people who canleast afford to have the thing
denied.
So that's a perfect use casefor somebody doing it for them.
(14:31):
And then medical necessitythat's one where you have to
kind of go get doctors todetailed site why something is
needed, you know, pullreferences from medical journals
or other cases and say thistreatment is needed for X, y, z,
and that's another thing wheremost kind of lay people will be
like I lack the expertise to.
So over the last several monthswe built a set of AI tools
training them on a lot ofdatabases of seeing what
successful appeals have worked,which things have even gone to
(14:51):
independent review, which haveworked, even training it on
legal databases that have thingsall the way gone to court and
then learned successful appealstrategies and been able to real
timetime access journals andmedical literature databases as
well as billing code databases.
To say, for any person whocomes in, whether in a rural
(15:13):
area, urban area, uneducatedperson, minimally educated or
super well-educated you know youcould even be a doctor yourself
.
Come into Counterforce Healthand upload your policy document,
upload your denial letter,upload any relevant information,
and just one click and sitthere and in less than two
minutes, a super detailed,well-crafted, eight plus pages
(15:35):
appeal letters with detailedcitations will be done for you
at no cost, and we run itcompletely for free.
By the way, it's a socialmission, you know.
I really just wanted to offerit to individuals for free.
So you know that I think can'tbe beat.
I think a lot of individuals,even if they had a brother
that's a doctor might still havetheir brother.
(15:56):
Take, you know, six hours, 10hours, to write something like
that, and we can do it with AIin a matter of you know seconds.
It, having trained on tons andtons of databases, absorb really
good information.
And then to your point about whothe users are, believe it or
not, clinics are also using itand there, ultimately, that'll
be the path to sustainability isthat we find many clinics,
(16:16):
especially small practices.
You know we don't kind of likeinitially start and gear towards
big hospitals.
I think a lot of them aretrying to do this stuff in house
, and good for them, you knowthey need to be, but there's
many, you know.
We have a rheumatologist youknow it's two doctors running a
small practice here in a smalltown in North Carolina and they
see tons of patients and they'reaveraging something like 35 to
(16:37):
40 denials per week and theyhave one administrative person
that handles kind of scheduling,billing, payments etc.
And then whenever she has timeshe will write a few appeal
letters.
And you know I was talking toher a couple weeks ago and she
was like, yeah, typically we'llwrite maybe three, four letters,
if I can, per week.
You know it takes me a couplehours each.
It's a lot of work and she, youknow she has a full time job
(16:58):
doing other stuff.
This is an example where theystarted coming to Counterforce
Health.
Now she's writing 40 appealletters a week.
You know kind of like this andshe would say they're better
than what she was writing byherself because they're much
more detailed and, you know,kind of much better cited.
So I think that's really kindof the power of AI.
I really believe thatdemocratizing access to this.
You know it's like if theinsurers have weaponized AI,
(17:21):
it's now time to provideindividual patients and small
clinics the same weapon to fightback, because I think it's been
asymmetric warfare until now.
Speaker 1 (17:33):
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Find your power with Benapower.
And now back to ourconversation.
I know you guys are early inthe process.
Are you keeping stats withusers?
Are you asking them forfeedback on what the percentage
of claims that get denied areoverturned when they use the
system?
Speaker 3 (19:24):
Yes, yeah, yeah.
So we're keeping stats and sofar it's surprisingly good.
Now there might be an adverseselection bias, like people who
are more intending to fight cometo the thing, but on average
it's averaging over 70%, like72% as of last set, which is
like surprisingly good, I think.
Average appeal you know,average appeal win rates in the
country, depending on which statyou look at, are somewhere like
40 to 50%.
(19:45):
So there's already kind of anincentive of if you simply
bother to write a letter, evenif you don't use counterforce
health, write it yourself, dowhatever right, use chat, upt, I
don't care, just bother doingan appeal, you'll win 40 to 50%
of the time.
Then the better the appealletter is, the more you'll win.
So yeah, like it's really coolto see 70% plus win rate.
(20:05):
I mean that's, that'sunbelievable right.
And it's like billing codeerror related appeals.
I mean those are extremely,extremely easy to fix and
address and there it's just amatter of taking the time to do
it, medically necessary a littlebit harder.
In many cases it just won't bedone, but again, easy enough to
address.
And then there's sometimes backand forth.
But what we find in manysituations is that people just
(20:29):
due to inertia, intimidation.
We're just simply not botheringto do it.
And then post care denials areeven.
I mean, I think those are, youknow, terrible right, like where
people have these $100 bills,$200 bills, where insurers is
like frivolously denying andmost people like I'll just pay
it out.
You know, I was actually.
I was talking to a ladyactually that we helped through
our care platform, living with ametastatic breast cancer in her
(20:51):
mid 70s, and she's been takingthis one routine med for the
last couple of years, 50 bucks amonth, and it got denied.
And this is before she knewabout counterforce and she just
paid it.
And I was like why did you paythat?
Like, why did you bother?
And she's like, well, she'slike calculating, she's like
calculating.
She's like, yeah, the stress ofwriting a letter, the stress of
researching, you know fighting.
She's like I just don't want todeal with all that.
I'm already going throughcancer.
(21:12):
I'm thinking about how muchlonger I got.
So she just kind of said it'seasier to pay the 50 bucks.
So it's like those things in myopinion that should be a close
(21:35):
to 100.
A thing that spits out a letterin one minute, then sure that's
worth 50 bucks at a time.
Speaker 1 (21:38):
So I like building innovations like that.
Well, what's interesting is thepost-care denials are
particularly stinging, I think,because as one of our guests
over the last couple of yearscoined the term we've created
people who are functionallyuninsured.
They may have an ID card intheir wallet, but deductibles
and personal responsibilityamounts have gotten so high and
convoluted that they're out ofpocket for a bunch of money
(21:59):
anyway.
And so you're taking apopulation that can least afford
to have these claims deniedbecause they don't have avenues,
they don't have huge savings,maybe they don't have credit
card availability or whatever,and they're getting saddled with
this debt.
And you know that the initialstudy back years ago from, I
think, steffi Wohlhandler whenshe was at Harvard, about
(22:22):
medical bankruptcy was kind ofquestioned.
But there have been a couple ofnew studies about the number of
bankruptcies that are caused bymedical 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 thatyou're doing it as a passion
project.
Speaker 3 (22:39):
Yeah, no thanks.
I mean it's a passion projectthat's actually turning into a
startup Like we've beenapproached by a bunch of venture
investors.
People kind of realize there'slike a twofold thing that you
can make and we really all ourinnovations are like impact
innovation.
So even Keriaya itself it's notlike a traditional kind of like
venture funded caregivingcompany.
We're all backed by impactinnovators.
So Keriaya itself has fundingfrom the American Heart
(23:01):
Association, aarp, as well asseveral other smaller impact
investors.
And I think same thing withCounterforce Health.
We're being approached byimpact investors like that who
want to build somethingsustainable but aren't really
sitting there trying to profitmaximize and they're just like
OK, as long as it can survive onits own.
So you know, kind of like themodel is free to people
indefinitely, like we spentupfront costs building it, the
ongoing cost is not very high.
(23:21):
And then really clinics as theysee value and really from a
clinical perspective it'srevenue cycle management right
that a lot of the denials,especially post-care denials,
will end up going intocollections.
Something like 10% to 15% ofthose will just not be paid and
then that's a problem for theclinic that they're going to
lose.
You know, if you kind of likedo the math on these couple of
(23:45):
providers experiencing 50 a week, you know, just, even if
averaging is $200 over thecourse of a month and seeing 200
, 300 denials, that's going tobe $40,000 plus.
And if 15% of those go tocollections, that's a disaster.
Right, that's a multi-thousanddollar problem per month.
So over time, from asustainability pathway, it's
going to be okay.
Will places like that say, hey,it's worth 5% of my, how much
(24:06):
revenue I'm capturing back tospend on a product like this.
So I'd say early, you know,kind of like how much revenue
I'm capturing back to spend on aproduct like this.
So you know, I'd say earlyconversations there, but like no
real pressure to monetize.
But I think investors reallysee the potential and I think
that passion project can turninto something huge.
Because I do believe, from apatient side, if you charge it's
tough, you know, because nowall of a sudden you have people
who are already hesitating ordon't want to fight it and then
(24:30):
you say, hey, five bucks to usethis.
People are like, nah, even ifit's on a success base, I just
feel like charging one isn't theright thing to do and I'll say
from the inside, not to marketagainst myself.
But the cost is not very high.
The cost per generation isfairly low.
It's a fixed cost business thatrequires a lot of software
development upfront and itrequires constant training and
retraining of models, but thevariable cost of the business is
(24:53):
absurdly low.
So you want to just go formaximum usage and maximum scale,
and I think that's also how youcan make maximum impact.
Speaker 1 (25:01):
So yeah, Well, I think you're right.
I think you know it's a gooddeed to do it on a public basis,
but the sustainability isreally going to be at the
doctor's office level and at theclinic level.
I cannot tell you how often Ihear you hear it too the system
is broken.
No, the system's not broken.
The system is working perfectly.
It was just never designed towork for you.
(25:23):
Yeah, and so if revenue cyclemanagement is one thing, but
certainly the 30% that theyreclaim on claims that go into
collection would more than payfor somebody to do this if they
had a system to do it, and Ilove the idea of okay, you're
using AI, here's AI back at you.
Speaker 3 (25:43):
Yep Agreed, and I didn't even get to the most fun
part.
And I didn't even get to themost fun part.
The other AI and I'll send youa video of this if you want to
include in the YouTube is weeven fully built a voice AI and
even a video avatar AI.
That's in beta right now butsome people are using because
just sending the letter, youknow, faxing that or mailing
that isn't where the battlestops.
Everybody knows you got to geton the phone with these
(26:03):
insurance companies, waste a tonof time on calls, right?
You see all these patientadvocates doing this on behalf
of people, right, and you know?
So we were like you can even AIthat.
So we built Maxwell, which is avoice AI assistant.
That actually the goal isupload all this stuff, generate
the letter and then have sickMaxwell on the insurance company
and he'll call the insurer onyour behalf and deal with the
(26:27):
process for you of just likewasting time with the claims and
billing people.
And I think that is interestingbecause they've deployed AI
bots.
So you know, whenever you callinsurers, like and we do this
all the time just as like apassion project where we have
people using our thing, and ifit's like a massive claim, we're
like, okay, let us help youmanually, just kind of for
learning and for fun.
And you know you call one ofthese insurers on behalf of
(26:49):
someone and you spend minutesand minutes going through the AI
bot conversation.
Then you get the rep on theline.
You know the rep is justwasting your time asking the
same questions.
This is another perfect use caseof AI, because the insurers
have weaponized voice AI on youand you can weaponize it back
and say, okay, my AI Maxwell isgoing to call and then one click
the whole thing.
The benefit there is if you'rea cancer patient, you're
(27:10):
somebody living with dementia,you're somebody who really
doesn't have the resources orthe ability to handle all the
stress to manually fight thisback, you can just have kind of
the AI do it for you.
And I think that that's goingto be a big thing of AI agents.
I know a lot of people havebeen talking about this, but I
think in these kinds of fields,from a consumer standpoint, not
enough people have developed AIagents and I think that's really
the opportunity of like havethe AI do as much of the grunt
(27:32):
work and the dirty work for you.
And I think at that point itmakes it more of a fair fight.
Speaker 1 (27:37):
What a fascinating journey you're on.
I do hope, as you grow out,you'll come back and we'll talk
some more about all this, and wewill do another separate
episode about CareYaya and whatit does, because people who are
caregivers are the unrecognizedheroes in healthcare, and it is
a huge burden and sometimes canbecome as debilitating for the
(27:59):
caregiver as it can for thepeople who are receiving care,
and so I'm more than happy tohave you back to talk about that
.
Neil Shaw, chairman andco-founder of Counterforce
Health.
Neil, thanks so much for afascinating conversation.
Speaker 3 (28:11):
Thanks for having me, david, really appreciate it.
Speaker 1 (28:19):
I want to give a quick shout out to our sponsor
and our producer, hatcher Media.
Hey, if you need podcastproduction or professional
graphic design, josh Hatcher isthe expert to contact For more
information.
Visit him at hatchermedianet.
That's H-A-T-C-H-E-R media dotnet.
Speaker 2 (28:38):
This Shift Shapers podcast is copyrighted content
and may not be reproduced inwhole or in part without the
express written permission ofShift Shapers Solutions LLC.
Copyright 2024.
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