Two years after a Bay Area woman gave birth, she said she received a nearly $2,000 bill saying her health insurance wouldn’t cover part of her maternity stay. She said she fought it and got nowhere until she decided to use artificial intelligence.

Lauren Gonzalves has been fighting her health insurance denials since she received the bill in 2023.

“My baby boy, now almost 4, received a bill for almost $2,000, adjusted down from $9,000,” Gonzalves, who lives in Concord, told CBS News Bay Area. 

She gave birth to her son in 2021, and said she first received a bill from Anthem Blue Cross Blue Shield two years after he was born.

“Anthem denied your claim, and they’re not going to pay this part of your maternity stay,” she said. “I was very surprised by this bill.

“The original bill actually had a charge for almost $9,000 for nursery charges,” Gonzalves added. 

She shared that she paid around $2,300, which was her out-of-pocket maximum while she was in the hospital. So, the new charges were unexpected. 

“They had denied the claim, but couldn’t exactly tell me why,” she said. “And then I had these different Anthem reps essentially come up with reasons as to why we have been billed.”

She filed several appeal letters to Anthem but was unsuccessful. 

“As I continued to fight with Anthem, they did something very interesting. They changed their bill from being under my name to being under baby boy Gonzalves, which was his alias in the hospital. And I thought the only reason they could be doing that was that they could essentially charge me for an out-of-pocket maximum for my son,” she said. 

Health Insurance Bill

A Concord woman decided to appeal a claim denial she received two years after her maternity stay. She said, at one point, the name of the bill even changed to that of her toddler. 

CBS News Bay Area

“I have this collections bill, which has also now showed up on my credit report. So, this has real consequences for me,” she said. 

Confused as to why Anthem denied her claim, she decided to turn to AI technology. 

“The AI said now there’s a timeliness issue. Anthem may have violated its own policy,” she said. 

Gonzalves learned about Counterforce Health through a friend and found herself on the other end of the line with AI Agent Maxwell. 

“He was able to give me all this information about different ways that I can continue to fight my claim,” she said.

Neal Shah is the CEO of Counterforce Health, a free platform that utilizes AI to fight back against denied health insurance claims. 

“For the average person, this is going to take five to 10 hours of extremely detailed research trying to find out incorrect billing codes, trying to prove medical necessity when you need something, going through your coverage policy documents, building a case almost like a legal case,” Shah told CBS News Bay Area. “And because of that being so intimidating, most people will just give up.”

“Ninety-nine percent of denied claims are never appealed. So, people just say I’ll either go without that or I’ll pay out of pocket. Of the 1% that are appealed, 50% of people win at baseline. Just goes to show you two things: that denials are unfair, and then people are not bothering to fight back. But if you bother to fight back, there’s a chance you may win,” he added. 

For Shah, the fight is personal. 

He was taking care of his wife, who was undergoing treatment for cancer, and dealt with several health insurance denials. 

“It’s at the darkest time of your life, when you’re going through cancer, when you’re going through major chronic illness, when you are sick and you are so stressed about fighting the disease, you now have to dedicate a lot of your energy to fighting the insurance company,” Shah said. 

And that is why he decided to build a free platform that families and clinics across the country now utilize to appeal insurance claim denials. 

“The denial rates have skyrocketed because there isn’t oftentimes even a human reviewing it. It’s just an AI system, and in one second denies you, and then you have to spend eight hours, 10 hours, doing all this BS to fight back? So now it’s like OK, we’ll build AI and empower people to fight back in a second,” Shah said. 

He also runs a caregiving platform, CAREYAYA, where college students are trained to become caregivers for older adults nationwide. He has also partnered with students at UC Berkeley and Stanford.  

“Having people feel empowered, that they have some agency in this journey,” Shah said. 

And the tool empowered those like Gonzalves who had been battling her insurance company for years. 

“Family members had told me, ‘Just pay the bill, just move on.’ And that’s just not who I am. I’m a social worker. I was going to advocate for myself. I was absolutely not going to give Anthem money that I did not owe them,” Gonzalves said.

Using the tools that Agent Maxwell had provided her, she then filed another appeal to Anthem. And in early August, the health insurance company dropped all of her charges. 

“You can imagine for the average person who is not in the medical field, they might just give up. They might just pay this bill or let collections ruin their credit,” Gonzalves said. “Insurance companies are supposed to support us and help us make sure that we get healthcare. But instead, they’re going after us, and they’re essentially trying to wear us down to earn money off of people’s exhaustion, and it’s not right.

CBS News Bay Area reached out to Anthem for comment and is waiting to hear back.  

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