Fighting for health care claim approvals

Marketing executive Mathew Evins has suffered from chronic back pain for eight years. He described it as “excruciating”. By 2024, he was having trouble walking. He had exhausted non-invasive treatments and his doctors agreed he needed surgery.

His insurance company had other ideas: “They went back to my surgeon and said, ‘Your patient needs another six weeks of physical therapy,'” Evans said.

So Evans reluctantly agreed and spent another six painful weeks. Even after that, his insurance company denied coverage again and again. “Emotionally, it’s been a roller coaster ride,” he said. “Physically, I just wanted some relief.”

But there was no relief. Seven months have passed. His condition worsened. “Everyone I saw said, ‘If surgery isn’t done soon, this damage could become more serious and/or permanent,'” he said.

27 million Americans don’t even have health insurance, so Evans considers himself lucky… until he actually needs it. He agreed that insurance companies should have a say in coverage, “but they shouldn’t have a decisive say.”

Most Americans agree; 73% say delays and denials of medical care are a major problem.

“That’s not the case, health care providers are the angels and insurance companies are the devil,” said author Katherine Hempstead. “I mean, we could do another show about hospital pricing. But I think consumers are going to feel like, ‘Hey, doctors are actually doing something. They’re trying to do something that they say is going to help me. And this middle man comes in and says they can’t do it.'”

Hempstead, a senior policy officer at the Robert Wood Johnson Foundation in Princeton, New Jersey, has seen this happen over and over again: “I just heard a story yesterday about someone who actually benefited from taking Botox for migraines and then suddenly denied it.”

Jeff Witten said that 20% of insurance claims (one in five) are denied, which was the main reason he and Ben Howard co-founded a company called Sheer Health. “Our goal is so people never have to deal with their health insurance again,” Howard said.

Patients simply take a photo of their bill and upload it to Sheer Health. “We’ll take care of everything,” Howard said. He means everything. Sheer Health will fight every insurance battle on behalf of each customer, either for $40 per month or on a pro-rated basis after refund.

The Sunday Morning Post contacted AHIP, the national trade group for health insurance companies, for comment. The organization’s response was, in part: “…health plans, providers and drug manufacturers all have a responsibility to make high-quality care…affordable…and easier to navigate…”

But Mathew Evins had been trying unsuccessfully to get coverage for back surgery until he found Sheer Health. Schell reviewed every word of his policy and authorization request, filed an expedited appeal with his insurance company, and worked with his doctors just to understand the authorization issues.

“Shell fixed everything,” Evans said. “I finally had surgery in mid-October.”

The result? “I’m doing great.”

Katharine Hempstead thinks Sheer Health’s success illustrates the failure of our health care system: “I think it’s a shame that we need it. It’s treating a symptom, you know, which is generally a good business idea, but it doesn’t make me feel like, ‘Okay, this is what we need.'”

She agreed it was the equivalent of buying insurance for your insurance.

With or without Sheer Health, what we clearly need is a system that works. “These insurance companies have people’s lives in their hands. Take this seriously. You are not their doctor. Don’t do this,” Evans said.

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Story by Amir Weisfogel. Editor: George Pozderek.