Julie Wernau

About three quarters of those people are successful. And so that's a pretty good figure.

When someone gets a denial, often they might be in one of the worst emotional moments of their life. And so that prevents a lot of people from moving forward.

After she got better from the illness, her mom noticed a remarkable change in her. She said she was like a totally different little kid. She was suddenly having really horrible behavioral problems and all sorts of issues. And it turned out that she had an inflammatory brain disease that was affecting her in multiple ways. And no one in their area seemed to be able to treat Emily.

It was a really rare condition.

They kept getting denial after denial for this treatment. First, you know, they said that this treatment was out of network for their pharmacy. That was two months of delays. Then the insurer came back and said they actually didn't think that this treatment was medically necessary. They didn't think it was provable.

They were just thrilled. You know, they were toasting with champagne. Even Emily really understood that it was a big moment. She had seen her mom cry multiple times trying to get her treatment and help. And so the next phase is actually waiting to see if it works.

I mean, you know, the whole world of insurance is sort of making decisions around what should and shouldn't get paid for in the case of various kinds of disasters, wildfires, car crashes. I think it feels different to people when you're talking about their health, right? This is literally life and death. How could it just be about money?

People, they look at a task before them and they say, is that something I can manage? Is that possible? And most people get overwhelmed before they start when things seem impossible. You know, I'm taking care of... an aging parent and trying to get my kid to school and put food on the table. And I don't know anything about scientific studies.

And I don't feel comfortable calling my doctor and asking him to write me a letter of recommendation. And I wouldn't even know who to call. So that's why.

What insurers say is it's their job to try to rein in the costs of our very expensive health care system and sort of toe the line of science and research, even if that means that particular treatment or something that's a little new could have saved that person's life. It's not about the individual.

So, Julie, who would have made that recommendation? Largely, we're talking about doctors and nurses. Okay. So these insurance companies have a staff that are actually clinicians. And their job is to look all the documentation over and then compare it against these insurance policies within these insurance companies. Their only job is to really like say, does this jibe with our policy?

And if it doesn't, then it gets denied.

I saw denial letters where essentially it was a line that said, this is an unproven treatment. I saw denial letters where it referred to some kind of issue with the drugs they needed and Often, it doesn't even refer back to any backup information to help you understand why the denial wasn't in line with their policies or in line with the accepted science.

A lot of times that might involve some studies showing that the treatment is warranted, maybe some history about the patient. And that usually goes to sort of like a higher level within the insurance company. If that gets denied, then often the next step is in a lot of states, you go to this sort of outside third party that reviews these insurance claims.

And then if that doesn't work, there's actually an appeal process that a patient can go through inside that third-party system. It's almost like a court case.

The way the system is supposed to work is that if your doctor has, you know, a peer-to-peer, as they call it, conversation, then that person legitimately is a peer, right? This is like if it's an oncologist, they're talking to someone who specializes in oncology. In reality, though, that is not always how it works.

And sometimes, you know, one person who is a specialist ends up speaking to a generalist. Or sometimes a specialist whose specialty does not even align with the case that they're looking at.

Absolutely not. That seems pretty complicated to navigate.

Doctors the journal spoke with made it clear they disavow the shooting of the UnitedHealthcare CEO. Still, broadly speaking, doctors had two main complaints. One, patients are being denied treatment. And two, doctors are having to fight with insurance companies to get paid. It's something doctors have to deal with every day. And they say both issues are getting worse.

So after talking to so many doctors about the state of the insurance industry in the U.S., what's your takeaway?

That's all for today. Thursday, December 19th. The Journal is a co-production of Spotify and The Wall Street Journal. Additional reporting in this episode by Josh Chaffin and Ana Wildey-Matthews. Thanks for listening. See you tomorrow.

Welcome to The Journal, our show about money, business, and power. I'm Ryan Knudson. It's Thursday, December 19th. Coming up on the show, why doctors are fed up with insurance. How complicated would you say the insurance industry is?

How did insurers come to play this role in our healthcare system?

Still, many doctors say the system isn't working. They're seeing more and more insurance companies denying the care they prescribe. From a non-clinical standpoint, that's the worst part of my job. That's Dr. Alan Nguyen, a spine specialist in Fort Myers, Florida.

How much time do you spend dealing with insurers?

So how often does care that you're recommending get denied by an insurance company?

In Alan's case, he often has to lobby insurance companies to approve treatment before he can implement it, a process called pre-authorization. If it doesn't get approved, he can't do it unless the patient pays out of pocket. One procedure that he says gets denied a lot has to do with patients dealing with a spinal fracture.

The killing sparked a broader conversation about the role of insurance companies in the healthcare industry. And that conversation has found its way into Julie's inbox. She's been getting a ton of emails, many of them from people who are frustrated with their insurance companies. And one thing Julie's been surprised by was how many emails she's received from doctors.

What reason do insurance companies typically give for and denials it?

Health insurers say denying certain treatments is an important way for the entire healthcare industry to keep costs down.

I asked Alan about this. What do you say to the insurance companies that say that, like, they're just trying to keep prices down and that physical therapy is a good and cheaper and less invasive option that ought to be tried first?

Julia says this is an experience she's heard from a range of doctors. They say these denials can discourage many patients from getting the treatments they need.

Our colleague Julie Wernow covers health and medicine. And for the last few weeks, she's been writing about the UnitedHealthcare CEO who was shot and killed in midtown Manhattan earlier this month.

Sometimes before an insurance company will approve a claim, they require something called a peer-to-peer review.

The idea is that it's an actual doctor at the insurance company who helps make the decision. The process usually requires the doctor submitting the claim to build a case for why an insurance company should approve and pay for the treatment.

Alan has had mixed experiences with the peer-to-peer process.

Can you just walk us through some of them and like maybe quote a couple?

I mean, how do you feel about the fact that part of your job is doing that? You can't just make a decision that you also have to then go and justify it with an insurance company.

When an insurer denies a treatment, there is an appeals process, though doctors say it can be cumbersome. AHIP, the health insurance trade organization, says the U.S. health system is, quote, fragmented and heavily regulated.

It added that health insurance companies are, quote, working to protect patients from the full impact of rising costs while connecting them to care that is safe, evidence-based, and coordinated. A lot of other doctors we've learned feel similarly to you. A lot of other doctors have written into the Wall Street Journal about this issue. Does that surprise you?

Mm-hmm.

Coming up, how tussling with insurance companies can affect a doctor's business.

Dr. Keith Berger is a gastroenterologist in Virginia. Keith runs a private practice, which means he's his own boss. Medicine runs in a family, and so Keith says private practice made a lot of sense for him.

She read me several of them.

So how would you say that your relationship with insurance companies affects your practice financially?

Keith says there's a variety of reasons he lost money last year, including higher expenses and fewer patients. But he says insurance delays and denials are part of it.

For Keith's staff, that thorn is also very time consuming.

How long do you want to play? Have you thought about selling your practice?

Insurance companies, of course, aren't solely to blame for the problems doctors are facing. Pharmaceutical companies, government regulators, and large hospital conglomerates also contribute to some of the same issues patients and doctors are frustrated with.

Are you surprised by what you heard from doctors? What do you make of the fact that so many are angry?

We're in cannabis country here. I'll show you the greenhouses over there you can see.

I guess I'm just surprised how packed together it all is. And you can smell it. Can you smell the pot? Oh, yeah. Yeah, right.

So this is Pueblo County, and this is where all the pot stuff started. And this whole area was filled with pot stuff.

Well, it looks like a lot of abandoned businesses. You see anything in there? It looks empty, right? Yeah. So this is a big pot place. Wow. Yeah. A lot of these are closed. Right here is a dispensary. So this is the second one you've seen. It's not like, I'm not seeing like big full parking lots. No, I never see cars there.