MICHEL MARTIN, HOST:
After the shocking murder of the United Healthcare CEO on the streets of Manhattan last week, many people have also been shocked by the outpouring of venom on social media directed at insurance companies that was prompted by the news. Many of the postings described situations where care was denied for seemingly nonsensical reasons and detailed the anguish and stress those denials provoked.
We wanted to go deeper than the anecdotes, though, so we called Miranda Yaver, who's been researching coverage denials for a forthcoming book. She teaches public health policy at the University of Pittsburgh, and she's also the author of a Substack called Rationing by Inconvenience. Professor Yaver, thanks so much for joining us.
MIRANDA YAVER: Thanks so much for having me. I appreciate it.
MARTIN: So you surveyed more than 1,300 Americans for your forthcoming book. What have you found to be the leading causes of denials?
YAVER: Yeah. So I interviewed 1,340 U.S. adults - found that 36% of them had experienced at least one coverage denial. Most of them experienced multiple denials. And these were really for a broad range of care, from prescription drugs to high-tech imaging to procedures to higher-level behavioral health care. A lot of this was through prior authorization or insurance preapproval. Some of it was later down the line, where the care was received, but they ended up getting an unexpected bill. So this is just a very diverse, wide-ranging patient experience for a lot of Americans.
MARTIN: Do we know the process that insurers use to decide whether to authorize claims or deny them?
YAVER: Yeah. So the frustrating thing for a lot of patients is that there's just a lot of opacity. When people have tried to dig into the rationales for claim denials, insurers have come back and said that this information is proprietary. What we do know is that people - when you get a denial, you're going to get a letter that will say, for example, that this is not a covered benefit, or there wasn't a prior authorization, or this is not medically necessary, or this is experimental or investigational. But sort of getting under the hood is something that is really challenging for us because then we have to figure out - is this something I'm actually supposed to be able to get, and how do I rebut the determination?
MARTIN: Do you have a sense of whether AI plays a role in this, now that this technology is so widely available?
YAVER: Yeah. So this has been an increasing challenge in recent years. So United Healthcare, Cigna and Humana were all just hit in the last year or so with class-action lawsuits over their use of AI in bulking - bulk-processing prior authorizations and claims. And one of the things that the lawsuit points out is that 90% of the denied claims were reversed upon appeal.
MARTIN: Ninety percent?
YAVER: Ninety percent - you heard me correctly. And that is just a wild figure because this really suggests that there is a high error rate. And what we've also seen in some of the research surrounding this is that claim denials went up pretty markedly in the aftermath of the implementation of these AI programs.
MARTIN: So it's kind of - we're only down to our last couple of seconds here. And I think anybody who's ever gotten one of those letters knows that, you know, appealing this can be daunting in itself. So California has passed legislation that takes effect next month that requires insurance companies to rely on the healthcare provider's advice first and not depend on algorithms. Do you think that this should be a model for the rest of the country?
YAVER: You know, I think that, you know, we'll know more when it gets implemented. It goes into effect January 1. But I think that this is a really productive way in which we can move the needle on health policy, which has historically been very challenging for us in this time of hyperpolarization because, at the end of the day, we want physicians to be reviewing these issues.
MARTIN: Miranda Yaver teaches public health policy at the University of Pittsburgh. Professor Yaver, thanks so much for joining us.
YAVER: Thanks so much for having me - appreciate it. Transcript provided by NPR, Copyright NPR.
NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.
