Investigating Health Insurance with Reporter Maya Miller 

Thank you for doing this interview. When I was in grad school, I had an overseas internship in a country where the CDC recommends getting a rabies vaccine if you’ll be there more than a month or will be spending time outdoors. Since I met the qualifications, I called Aetna before scheduling the appointments for that vaccine, and the rep told me that they would cover it since I met the CDC guidelines. I got all three doses through the campus clinic, got to the end of the semester, went to register for classes, and found a $500 hold on my account from the clinic. I called Aetna back, and that rep told me they weren’t covering the vaccine, didn’t explain why, didn’t care that a different rep told me it would be covered, and didn’t even hint that I could appeal. If I ever need non-standard vaccines or treatments again, I’m gonna get confirmation of coverage in writing, because I’m not putting up with that a second time.

Boss: Jimothy, we have to talk. We've received a concerning report from a journalist. She says that, according to our own records, you deny claims in an average of 1.2 seconds. Jimothy: So? Boss: Jimothy, this is not acceptable in our company. Didn't you take the mandatory training when you joined? Jimothy: Um, yeah... but I don't remember anything in the training about having to perform due diligence on a claim before denying it. Boss: What's "due diligence"? Jimothy: ... Boss: Never mind. The point is, didn't they teach you to use the keyboard shortcuts? All you have to do to deny the claim is press the Enter key. It takes me an average of 0.243 seconds on average to press Enter. That's 4.94 times as fast as you're doing it, Jimothy. Why am I 4.94 times more efficient than you? Jimothy: How do you know it takes you 0.243 seconds to press the Enter key? Boss: Our system tracks this, Jimothy. These numbers are used for performance metrics. How do you think I got to be your boss? You didn't really think it was because of my medical expertise, did you? Jimothy: Wait -- you have medical expertise? Boss: Of course I don't. Now, the next time we appear in a ProPublica report, that number needs to be under 1 second or I'm putting you on a PIP. Understood?

I'm a cancer researcher who manages data for phase 1 clinical trial patients, and my mom is an executive assistant for one of the biggest health insurance companies in the US. My poor mother (bless her heart) is blissfully unaware of all the evil these companies specialize in that profit from and financially devastate people like our stage 4 cancer patients, and always likes to say things like "isnt great how we both work in healthcare sweetie?"... it makes me die a little inside because anyone not working in health insurance would probably describe them more like "healthcan't" than "healthcare".

I'm a professor in a speech-language pathology graduate program. I show your videos in my medical caseload management course when we discuss insurance, denials, prior authorization, etc.

Exactly Kristin. Appeal. Appeal. Appeal. Thank you both for this so much. Yes, advocacy works.

My favorite critical care ophthalmologist! Even if I knew of any others you’d still be my favorite

I ordered an MRI for a young female pt of mine with a constellation of unusual neurological symptoms that were intermittent. Insurance denied it. I called to do the peer to peer, and they sent me to a nurse who assured me that she was the person I was supposed to speak to. I finally got to a “doctor” who told me she was going to deny it bc “you don’t need an mri for this pt. She has a history of carpal tunnel.” Ma’am, THAT DOES NOT EXPLAIN LOWER EXTREMITY WEAKNESS OR TRANSIENT LOSS OF VISION. I got it approved, and my pt has MS. And the insurance denied her MRI. I should have stuck with talking to the nurse. Multiple neurological symptoms separated in time is basic 1st year med student diagnostic criteria for testing for MS.

Wow great way to start my day

Look.... I know our taxes in Denmark are much higher than yours, but damn, I'm still glad I had no idea what prior authorization, co-payment, deductible, out-of-pocket costs, etc. were until I started watching your videos.

Listening about the leeches , I also wanted to let you know about maggots being used in cases of debriding deep wounds and necrotizing facitis.

It took 1.2 seconds for me to get really mad.

The use of leeches is straight forward. When doing a surgical repair like replacing a finger tip it is possible to anastomose (stitch together) the arteries, since the arteries have a muscular wall. Small veins are much harder and often impossible to stitch together since their walls are very thin and fragile, so leeches are used as to augment venous drainage thus preserving a degree of perfusion (blood flow) to the tissue while the venous drainage reconstitutes itself during the healing process.

FYI - Most States in the USA have Insurance Departments that allows you can file a complaint.

Remarkable podcast. As a retired public health official, I know how horrific emergencies were in 2020! I am still processing so many experiences from those years…. I cried off and on during this broadcast. Well done!

There are some podcasts I hear and think, wow some people should hear this. This one I feel EVERYONE should hear and ACT! It affects all of us. Thanks for firing me up!

I love how she brought up appealing. I had the fortune of being on my dad's insurance until i turned 26, so Ive only been on my own insurance for 2 years so far, but i know that whenever i get a slightly high bill, even if it's just a few hundred dollars and i technically have the funds to pay it, I contact my insurance first. It's happened where my insurance replied back to me saying I needed to pay a bill, and after I did, I was later refunded. Never pay more than you are supposed to!

Care manager here. One important thing to know is how to do an OFFICIAL appeal when it’s a Medicare advantage plan. Peer-to-peer appeals are considered unofficial appeals. You have to send the appeal to the fax number on the denial letter.

This was very fascinating, especially as a European person. We, too, have nonsense going on, but it's not quite that horrifying and complex. And really It's so fascinating to me how much money insuranced throw out the window by having ppl sit there and deny stuff without even doing their blasted job! Aka money is invested into people specifically being unhelpful to everyone, sometimes including themselves, if they struggle marally! 🤯 People are paying people to deny them help. That's what this is.

Watching this while submitting health insurance claims. Half of which will be partially denied.

I only now noticed Dr. has gained handsome grey in his beard.

Ah yes, reminds me of last year when I was told in order to get my prior auth approved I needed to provide medical records from the time of my diagnosis… in 1999… or else I’d have to pay $7000 a month for medication I’ve taken every day for 25 years.

this is amazing and streamlining appeals with a form builder will literally save lives, not to mention saving people from millions of dollars in medical debt, while helping to hold the world's 10th largest corporation (among others) accountable to future patients. in a country where most disease is preventable, and most detected disease is treatable, barriers to access are the biggest threat to public health. these journalists are as much healers as any doctor to the extent they remove those barriers to access -which are overwhelmingly profit-driven ones, and profitable for the bastards responsible.

As to the reason the insurance in America works this way is because the insurance company knows the majority of people are not going to understand how to research and begin the appeal process, let alone fill out all the papers and deal with the adversarial appeal personal. The insurance count on the public's ignorance and desire for conflict avoidance to get away with their nefarious practices.

What I dont get is this constant onslaught of prior auths for chronic health medications patients have been on and doing well with for years, many of them not expensive!

I hear concern on this channel about leeches used in medicine, but I do not hear anyone on this channel mentioning what might be another level beyond leeches: maggots are sometimes used for wound debridement.

Screams with rage in autoimmune arthritis. If I knew the right people I would go to the highest court that would take us and make the claim that this process is cruel and unusual punishment. Here is my idea for a skit featuring Jimothy. It would bring me such joy if you would make it Us: I'm in so much pain I want the eternal night night. Can you help? Rheum: You need a biologic Jimothy: No. Go to physical therapy and You haven't failed MTX long enough Us: Ok, so six months of MTX and I'm still in agony. Can I have something for pain. Jimothy: PT wasn't needed. Claim denied. Take Ibuprofen. You have now been identified as drug seeking Us: Ok, did that. Can I have the drug my Rhuem prescribed? Jimothy: No. You can only have this one. Us: Yay, this one is working. Hooray Jimothy: That one is no longer on our formulary. Claim denied. Us: Wait what? I guess I'll try the one on your formulary Rhuem: Sometimes when you stop a biologic, you can't go back. Be careful or you'll run out of drugs. Us: Whelp, since I can't afford $6-$8k a month, I guess I don't have a choice. Jimothy: That'll be another 3 month pre-authorization Us: But...I'm still in the eternal night night pain. Jimothy: More Ibuprofen. Have you tried MTX? Us: Hey I've been hitting the Ibuprofen hard and now am having trouble hearing.. Jimothy: Denied, we don't cover hearing Us: Thanks, I hate it here.

It is untrue that they are not making Health Care decisions because in my case they denied my pre-authorization for a much-needed city of my abdomen and when I asked the Imaging place if I could just pay for cash and what that would cost me they stated for their contract that until there is an actual formal denial which is garbage I can't even pay for my own imaging test

Everyone needs to listen to this podcast. We have Anthem BCBS and we have been fighting them for several different things lately. One example is my daughter had physical therapy and this was 6 months ago. They still haven't paid her bill. They say they denied her physical therapy and we were never told this by our insurance or the company she had the physical therapy done. She wouldn't have gone if she was told this. She's an adult so she isn't exactly old enough to even understand what she's supposed to say. Hipaa won't let me get involved because she's over 18. Maybe I will post it online.

I've always fantasized about turning two forces that clog up healthcare against each other, malpractice law and insurance. When an insurance company denies life-saving or morbidity-preventing care, how in the world is that not the same as malpractice of medicine? They made a decision about a patient's care, they turned the direction of a person's treatment. And in the cases of denials, what direction do you think that sends the outcome? Are insurance companies protected from that exposure? How great would be it to turn down the wasted time and energy in the song and dance done to decrease exposure for physicians and at the same time incentivize insurance companies to pay for the stuff they are literally in existence to pay for? Wouldn't the lawyers also love to hit up those juicy targets? Everybody (who isn't evil) wins!

Insurance is supposed to cover things (that aren't basic healthcare?)

I am subscribed to you but didn't see this video until 4 months later. Algorithm? In any case, I think it would be helpful to link to Pro Publica's stories on this as well as I suspect commenters here might get flagged if they try to link to the Pro Publica story in comments.