By Joshua Chaffin and Julie Wernau
The Wall Street Journal, Dec. 12, 2024
The killing of a top health insurance executive outside a Midtown Manhattan hotel last week triggered an outpouring of public anger at an industry many Americans blame for the ills of the nationâs healthcare system.
Count doctors among the aggrieved.
They deal day in and day out with insurers including UnitedHealthcare, whose chief executive, Brian Thompson, was shot to death last week by an assassin who targeted him outside the companyâs annual investor conference. Doctors say their frustration is born of intimate experience and has been building for years.
Their chief complaint is the aggravation and expense of convincing insurance companies to pay them for their patientsâ treatment. Even when they are ultimately approved, MRI scans and other vital but costly procedures often require days of campaigning and paperwork, say doctors.
âItâs getting worse,â said Dr. Zulfiqar Ahmed, an internist in Augusta, Ga., who has practiced in the U.S. for 35 years. âThis is not only UnitedHealthcareâthis is universal in this country.â
Like other clinicians, Ahmed made clear he was appalled by Thompsonâs killing and those who have justifiedâor even celebratedâit on social media. âMy heart is saddened for this Mr. Thompson,â he said. âHeâs just part of the system, part of this big enormous system.â
Still, doctors say that sympathy doesnât change their feelings about having to haggle with doctors employed by UnitedHealthcare and other insurers to evaluate proposed proceduresâand oftentimes, reject them. âThey hire certain doctors, and they sit at a desk, and their whole purpose is to deny or delay,â Ahmed said, echoing a common complaint among doctors.
Health insurers say they play a valuable role financing the medical care that saves the lives of many patients. Denials keep a lid on unnecessary care and high costs, companies say, thereby keeping treatment affordable for everyone. Insurers also note that doctors, hospitals and drugmakers play a big role in soaring healthcare spending that they are trying to restrain, while ensuring patients get the medical care they need.
In a message to employees Wednesday, UnitedHealth Group CEO Andrew Witty memorialized Thompsonâs âprofoundly positive impactâ on peopleâs lives.
Doctors won a rare victory over an insurer last week. In November, Elevance Healthâs Anthem unit had said it wouldnât cover anesthesiology claims for surgeries in Connecticut, New York and Missouri that went beyond a certain time limit, prompting outrage from specialists and even New York Gov. Kathy Hochul. It reversed course last Thursday, a day after Thompson was killed.
An Anthem Blue Cross Blue Shield spokesman said its policy change had been widely misinterpreted. âIt never was and never will be the policy of Anthem Blue Cross Blue Shield to not pay for medically necessary anesthesia services,â he added.
Americaâs Health Insurance Plans, a national industry trade association, said state laws dictate how long an insurer has to pay a provider and ensure that they are paid in a timely manner. Delays can be caused when providers go out of network or are using manual processes to submit claims and receive payments, it said.
The industryâs overall rate of prior authorization denials isnât public. Medicare Advantage plans, a popular form of health insurance, denied 7.4% of 46.2 million requests submitted on behalf of enrollees in 2022, up from 5.7% in 2019, according to an analysis of federal data by KFF, a health-policy nonprofit. A recent Inspector General audit found that 13% of prior authorization denials from Medicare Advantage plans were for benefits that should otherwise have been covered under Medicare.
Even when insurers pay, doctors may still find themselves on the hook. Consider the plight of Dr. Anthony Ekong, an ophthalmologist specializing in retinal care who has built a solo practice in Bangor, Maine.
Last month, Ekong received a stack of letters from a company called Cotiviti, which is an auditor for the insurer WellCare, a unit of Centene. In an effort to provide excellent customer service, Cotiviti wrote, it had reviewed payments Ekong had received for treating elderly patients with macular degeneration and macular edema. It determined WellCare had overpaid. The bill: more than $300,000.
âWe would have to shut down or file for bankruptcy,â said Ekong.
WellCare, in turn, suggested he make up the difference by billing his patients. But many are elderly and struggling to get by. Among them are Eugene Strout, 71, and his wife, Donna-Marie Strout, 72, who subsist on Social Security and Eugeneâs occasional shifts driving a school bus. At one point, Ekong offered to pay the couple to clean his office every week to help fund the $600 a month theyâd have to pay if they switched to another insurer. The Strouts ended up reluctantly moving their care to their local hospital, which still accepts their insurance. The Strouts worry that the hospital could also end up dropping the insurance.
âItâs egregious, invalid and a breach of trust,â Ekong said.
A representative for Centene said the company is looking into the issue further and hopes to amicably resolve it.
Andrew MacLean, chief executive of Maine Medical Association, said he receives phone calls every day from physicians struggling with health insurers demanding so-called clawbacks for bills that had already been paid.
âIt almost feels like they do it because they can,â MacLean said of the insurers. âBy no means do we applaud this or would we condone violence, but itâs a scary indication of just how frustrated people are about the current system and the imbalance of powerâand physicians certainly feel that.â
In a recent post on X, Dr. Alan Nguyen, a spine specialist in Fort Myers, Fla., noted that when insurance-company doctors reject an MRI request, he now asks for their name and health provider identification number. âI tell them if a cancer is missed, then the patient will know who to sue,â wrote Nguyen. In an interview, he said he believes the situation had worsened significantly over the last five years. When insurers denied treatment, Nguyen observed, doctors were still left to deal with the patients and their pain.
A familiar lament among doctors is how sweeping changes over the last 20 yearsâsome instigated by insurers, others notâhave degraded their profession. Once autonomous and highly esteemed, doctors are increasingly employees of large hospital chains and find themselves trapped between insurers and their own cost-conscious management.
âHealthcare is run by the business types,â said Dr. Mark Davidian, a radiologist in Sacramento, Calif., who despaired at the loss of agency when caring for patients. He took particular umbrage when he discovered from news reports that UnitedHealthcareâs Thompson earned some $10 million last year and then imagined how that might be received by a cancer patient who had been denied treatment.
When Davidian finished his training 25 years ago, things were different. âDoctors had their own practices. They called the shots,â he said. If, for example, he was dissatisfied with the staff or the equipment at a particular hospital, he would send his patients elsewhere, he said.
Nowadays, he works for a hospital chain in northern California, and feels bound by the prerogatives of managers determined to contain costs. âNobody speaks for the patient anymore that has any sort of power,â he said. âThe problem is, with healthcare weâre supposed to care.â
While larger chains may have the wherewithal to grapple with insurers, the costs weigh heavily on smaller practitioners.
Dr. Richard Lechner, a family dentist in New Britain, Conn., for years paid for three administrative staff members whose days, he said, were mostly spent fighting with insurers. This for an office that consisted of one dentist and two hygienists.
âTheyâre always throwing up roadblocks for practitioners like me to get paid,â Lechner said. Requests for additional documentation, or claims of paperwork lapses, were, he said, âspecifically designed to prolong, prolong, prolong and then hope the dentist gives up.â
Last year, Lechner did give up: He sold his private practice to Dental Associates of Connecticut, a company that operates a network of more than 40 dental offices across the state. Like Davidian, he is now an employee. Much of the work of chasing insurance claims is now handled by a specialist team at Dental Associatesâ central office.
âThe primary reason I sold my dental practice is because I couldnât keep up with the insurance companiesâ shenanigans,â he said. âI thought I was going to have a stroke.â
Joseph Walker contributed to this article.